Chapter 65 - Assessment of the Renal/Urinary System

A client has returned from a captopril renal scan. Which teaching does the nurse provide when the client returns? "Arise slowly and call for assistance when ambulating." Correct "I must measure your intake and output." "We must save your urine because it is radioactive." "I must attach you to this cardiac monitor."

Captopril can cause severe hypotension during and after the procedure, so the client should be warned to avoid rapid position changes and about the risk for falling as a result of orthostatic (positional) hypotension. Intake and output measurement is not necessary after this procedure, unless it had been requested previously. A small amount of radionuclide is used in a renal scan; the urine is not radioactive, although the nurse should practice Standard Precautions, as always, and wear gloves. Cardiac monitoring is not needed, although the nurse should monitor for hypotension secondary to captopril.

A client is scheduled for a cystoscopy later this morning. The consent form is not signed, and the client has not had any preoperative medication. The nurse notes that the provider visited the client the day before. What action does the nurse take? Asks the client to sign the informed consent Cancels the procedure Asks the client's spouse to sign the form Notifies the department and the provider Correct

The client may be asked to sign the consent form in the department; notifying both the provider and the department ensures communication across the continuum of care, with less likelihood of omission of information. The provider gives the client a complete description of and reasons for the procedure and explains complications; the nurse reinforces this information. The procedure should not be cancelled without an attempt to correct the situation. The client has not received sedation, so nothing suggests that the client is not competent to consent.

For which clients scheduled for a computed tomography (CT) scan with contrast does the nurse communicate safety concerns to the health care provider? (Select all that apply.) Client with an allergy to shrimp Correct Client with a history of asthma Correct Client who requests morphine sulfate every 3 hours Client with a blood urea nitrogen of 62 mg/dL and a creatinine of 2.0 mg/dL Correct Client who took metformin (Glucophage) 4 hours ago Correct

The client who will be undergoing a CT scan with contrast should be asked about known hay fever or food or drug allergies, especially to seafood, eggs, milk, or chocolate. Contrast reactions have been reported to be as high as 15% in these clients. Clients with asthma have been shown to be at greater risk for contrast reactions than the general public. When reactions do occur, they are more likely to be severe. The risk for contrast-induced nephropathy is increased in clients who have pre-existing renal insufficiency (e.g., serum creatinine levels greater than 1.5 mg/dL or estimated glomerular filtration rate less than 45 mL/min). Metformin must be discontinued at least 24 hours before and for at least 48 hours after any study using contrast media because the life-threatening complication of lactic acidosis, although rare, could occur. There are no contraindications to undergo CT with contrast while taking morphine sulfate. CT with contrast may help to identify the underlying cause of pain.

Which instruction does the nurse give a client who needs a clean-catch urine specimen? "Save all urine for 24 hours." "Use the sponges to cleanse the urethra, and then initiate voiding directly into the cup." "Do not touch the inside of the container." Correct "You will receive an isotope injection, then I will collect your urine."

A clean-catch specimen is used to obtain urine for culture and sensitivity of organisms present; contamination by the client's hands will render the specimen invalid and alter results. Saving urine for 24 hours is not necessary for a midstream clean-catch urine specimen. After cleaning, the client should initiate voiding into the commode, then stop and resume voiding into the container. Only 1 ounce (30 mL) is needed; the remainder of the urine may be discarded into the commode. A midstream collection further removes secretions and bacteria because urine flushes the distal portion of the internal urethra. A clean-catch specimen for culture does not require an injection of isotope, simply cleansing of the perineum.

The nurse has these client assignments. Which client does the nurse encourage to consume 2 to 3 liters of fluid each day? Client with chronic kidney disease Client with heart failure Client with complete bowel obstruction Client with hyperparathyroidism Correct

A major feature of hyperparathyroidism is hypercalcemia, which predisposes a client to kidney stones; this client should remain hydrated. A client with chronic kidney disease should not consume 2 to 3 liters of water because the kidneys are not functioning properly, and this could lead to fluid retention. People with heart failure typically have fluid volume excess. A client with complete bowel obstruction may experience vomiting and should be NPO.

When planning an assessment of the urethra, what does the nurse do first? Examine the meatus. Note any unusual discharge. Record the presence of abnormalities. Don gloves. Correct

Before examination begins, body fluid precautions (gloves) must be implemented first. Examining the meatus, noting unusual discharge, or recording the presence of abnormalities are things that the nurse should do after putting on gloves.

The nurse is reviewing the medical record for a client with polycystic kidney disease who is scheduled for computed tomographic angiography with contrast: History and Physical Assessment Medications Diagnostic Findings Polycystic kidney disease Diabetes Hysterectomy Abdomen distended Negative edema Glyburide Metformin Synthroid BUN 26 mg/dL Creatinine 1.0 mg/dL HbA1c 6.9% Glucose 132 mg/dL Which intervention is essential for the nurse to perform? Obtain a thyroid-stimulating hormone (TSH) level. Report the blood urea nitrogen (BUN) and creatinine. Hold the metformin 24 hours before and on the day of the procedure. Correct Notify the provider regarding blood glucose and glycosylated hemoglobin (HbA1c) values.

Before studies with contrast media are performed, the nurse must withhold metformin, which may cause lactic acidosis. The focus of this admission is the polycystic kidneys; a TSH level is not essential at this time. BUN and creatinine are normal. The glucose is only mildly elevated (if fasting), and the HbA1c is in an appropriate range.

The nurse visualizes blood clots in a client's urinary catheter after a cystoscopy. What nursing intervention does the nurse perform first? Administer heparin intravenously. Remove the urinary catheter. Notify the health care provider. Correct Irrigate the catheter with sterile saline.

Bleeding and/or blood clots are potential complications of cystoscopy and may obstruct the catheter and decrease urine output. The nurse should monitor urine output and notify the health care provider of obvious blood clots or a decreased or absent urine output. Heparin will not be administered due to bleeding. The urinary catheter is allowing close monitoring of the urinary system and should not be removed at this time. The Foley catheter may be irrigated with sterile saline, as ordered.

An older adult woman who reports a change in bladder function says, "I feel like a child who sometimes pees her pants." What is the nurse's best response? "Have you tried using the toilet at least every couple of hours?" Correct "How does that make you feel?" "We can fix that." "That happens when we get older."

By emptying the bladder on a regular basis, urinary incontinence from overflow may be avoided, which may give the client some sense of control. The client has already stated how she feels; asking her again how she feels does not address her concern nor does it allow for nursing education. The nurse cannot assert that the problem can be fixed because this may be untrue. Suggesting that the problem occurs as we get older does not address the client's concern and does not provide for nursing education.

Which technique does the nurse use to obtain a sterile urine specimen from a client with a Foley catheter? Disconnect the Foley catheter from the drainage tube and collect urine directly from the Foley. Remove the existing catheter and obtain a sample during the process of inserting a new Foley. Use a sterile syringe to withdraw urine from the urine collection bag. Clamp the tubing, attach a syringe to the specimen, and withdraw at least 5 mL of urine. Correct

Clamping the tubing, attaching a syringe to the specimen, and withdrawing at least 5 mL of urine is the correct technique for obtaining a sterile urine specimen from the client with a Foley catheter. Disconnecting the Foley catheter from the drainage tube and collecting urine directly from the Foley increases the risk for microbe exposure. A Foley catheter should not be removed to get a urine sample. Microbes may be in the urine collection bag from standing urine, so using a sterile syringe to withdraw urine from the urine collection bag is not the proper technique to obtain a urine sample.

Which laboratory test is the best indicator of kidney function? Blood urea nitrogen (BUN) Creatinine Correct Aspartate aminotransferase (AST) Alkaline phosphatase

Creatinine excretion, the end product of muscle metabolism, remains relatively steady and therefore is the best indicator of renal function. BUN may be affected by protein or fluid intake. AST and alkaline phosphatase are measures of hepatic function.

Which assessment finding alarms the nurse immediately after a client returns from the operating room for cystoscopy performed under conscious sedation? Pink-tinged urine Urinary frequency Temperature of 100.8° F Correct Lethargy

Fever, chills, or an elevated white blood cell count after cystoscopy suggest infection after an invasive procedure; the provider must be notified immediately. Pink-tinged urine is expected after a cystoscopy; gross hematuria would require notification of the surgeon. Frequency may be noted as a result of irritation of the bladder. If sedation or anesthesia was used, lethargy is an expected effect.

When a client with diabetes returns to the medical unit after a computed tomography (CT) scan with contrast dye, all of these interventions are prescribed. Which intervention does the nurse implement first? Give lispro (Humalog) insulin, 12 units subcutaneously. Request a breakfast tray for the client. Infuse 0.45% normal saline at 125 mL/hr. Correct Administer captopril (Capoten).

Fluids are needed because the dye used in a CT scan with contrast has an osmotic effect, causing dehydration and potential kidney failure. Lispro is not administered until the breakfast tray arrives. A breakfast tray will be requested, but preventing complications of the procedure is done first. Because the client may be hypovolemic, the nurse should monitor blood pressure and administer IV fluids before deciding whether administration of captopril is appropriate.

When caring for a client with uremia, the nurse assesses for which symptom? Tenderness at the costovertebral angle (CVA) Cyanosis of the skin Nausea and vomiting Correct Insomnia

Manifestations of uremia include anorexia, nausea, vomiting, weakness, and fatigue. CVA tenderness is a sign of inflammation or infection in the renal pelvis. Cyanosis is related to poor tissue perfusion. Insomnia is nonspecific and may be caused by psychoemotional factors, medications, or other problems.

Which urinary assessment information for a client indicates the potential need for increased fluids? Increased blood urea nitrogen Correct Increased creatinine Pale-colored urine Decreased sodium

Increased blood urea nitrogen can indicate dehydration. Increased creatinine indicates kidney impairment. Pale-colored urine signifies diluted urine, which indicates adequate fluid intake. Increased, not decreased, sodium indicates dehydration.

The charge nurse is making client assignments for the day shift. Which client is best to assign to an LPN/LVN? Client who has just returned from having a kidney artery angioplasty Client with polycystic kidney disease who is having a kidney ultrasound Correct Client who is going for a cystoscopy and cystourethroscopy Client with glomerulonephritis who is having a kidney biopsy

Kidney ultrasounds are noninvasive procedures without complications; the LPN/LVN can provide this care. A kidney artery angioplasty is an invasive procedure that requires postprocedure monitoring for complications, especially hemorrhage; a registered nurse is needed. Cystoscopy and cystourethroscopy are procedures that are associated with potentially serious complications such as bleeding and infection. These clients should be assigned to RN staff members. Kidney biopsy is associated with potentially serious complications such as bleeding, and this client should be assigned to RN staff members.

Which age-related change can cause nocturia? Decreased ability to concentrate urine Correct Decreased production of antidiuretic hormone Increased production of erythropoietin Increased secretion of aldosterone

Nocturia may result from decreased kidney-concentrating ability associated with aging. Increased production of antidiuretic hormone, decreased production of erythropoietin, and decreased secretion of aldosterone are age-related changes.

The RN is caring for a client who has just had a kidney biopsy. Which action does the nurse perform first? Obtain blood urea nitrogen (BUN) and creatinine. Position the client supine. Correct Administer pain medications. Check urine for hematuria.

The client is positioned supine for several hours after a kidney biopsy to decrease the risk for hemorrhage. BUN and creatinine would be obtained before the procedure is performed. Only local discomfort should be noted around the procedure site; severe pain would indicate hematoma. Although pink urine may develop, the nurse should position the client to prevent bleeding first; the other actions are appropriate after this procedure, but do not need to be done immediately after the biopsy.

A client had a computed tomography (CT) scan with contrast dye 8 hours ago. Which nursing intervention is the priority for this client? Maintaining bedrest Medicating for pain Monitoring for hematuria Promoting fluid intake Correct

The nurse should ensure adequate hydration by urging the client to take oral fluid or by giving IV fluids. Hydration reduces the risk for kidney damage. Bedrest is not indicated for the client who has undergone a CT scan with contrast dye. CT with contrast dye is not a painful procedure, so pain medication is not indicated. The client who has undergone CT with contrast dye is not at risk for hematuria.

A client is in the emergency department for an inability to void and for bladder distention. What is most important for the nurse to provide to the client? Increased oral fluids IV fluids Privacy Correct Health history forms

The nurse should provide privacy, assistance, and voiding stimulants, such as warm water over the perineum, as needed, for the client with urinary problems. Increased oral fluids and IV fluids would exacerbate the client's problem. Obtaining a health history is not the priority for this client's care.

One of the nurse's roles is talking to adult clients about urinary and sexual hygiene. Which words does the nurse use when referring to the client's reproductive body parts? Children's terms that are easily understood Slang words and terms that are heard "socially" Technical and medical terminology Words that the client uses Correct

The nurse should use the terms with which the client is most familiar, so there is no chance for the client to misunderstand information. Using the client's language ensures the comfort level for the client. The use of children's terms is demeaning to adult clients. The use of slang terms is unprofessional. Technical terms should not be used because the client may not know what they mean.

When performing bladder scanning to detect residual urine in a female client, the nurse must first assess which factor? Abdominal girth Presence of urinary infection History of hysterectomy Correct Hematuria

The scanner must be in the scan mode for female clients to ensure the scanner subtracts the volume of the uterus from the measurement, or in the scan mode for male clients for women who have undergone a hysterectomy. The nurse performs this procedure in response to distention or pressure in the bladder; girth is not a factor. This procedure detects urine retained in the bladder, not infection. The presence of retained urine in the bladder is assessed, regardless of hematuria.

A client with these assessment data is preparing to undergo a computed tomography scan with contrast: Physical Assessment Diagnostic Findings Medications Flank pain BUN 54 mg/dL Captopril Dysuria Creatinine 2.4 mg/dL Metformin Bilateral knee pain Calcium 8.5 mg/dL Acetylcysteine Which medication does the nurse plan to administer before the procedure? Acetylcysteine (Mucosil) Correct Metformin (Glucophage) Captopril (Capoten) Acetaminophen (Tylenol)

This client has kidney impairment demonstrated by increased creatinine. Acetylcysteine (an antioxidant) may be used to prevent contrast-induced nephrotoxic effects. Metformin is held at least 24 hours before procedures using contrast. Although captopril and acetaminophen may be administered with a sip of water with permission of the provider, this is not essential before the procedure.

The nurse is teaching a client how to provide a clean-catch urine specimen. Which statement by the client indicates that teaching was effective? "I must clean with the wipes and then urinate directly into the cup." "I will have to drink 2 liters of fluid before providing the sample." "I'll start to urinate in the toilet, stop, and then urinate into the cup." Correct "It is best to provide the sample while I am bathing."

To provide a clean-catch urine sample, the client should initiate voiding, then stop, then resume voiding into the container. A midstream collection further removes secretions and bacteria because urine flushes the distal portion of the internal urethra. Although cleaning with wipes before providing a clean-catch urine sample is proper procedure, a step is missing. It is not necessary to drink 2 liters of fluid before providing a clean-catch urine sample. Providing a clean-catch urine sample does not involve bathing.

Which percussion technique does the nurse use to assess a client who reports flank pain? Place outstretched fingers over the flank area and percuss with the fingertips. Place one hand with the palm down flat over the flank area and use the other fisted hand to thump the hand on the flank. Correct Place one hand with the palm up over the flank area and cup the other hand to percuss the hand on the flank. Quickly tap the flank area with cupped hands.

While the client assumes a sitting, side-lying, or supine position, the nurse forms one of the hands into a clenched fist. The other hand is placed flat over the costovertebral (CVA) angle of the client. Then, a firm thump is quickly delivered to the hand over the CVA area. Percussion is not appropriate for flank pain. Placing one hand palm up is not the correct technique. Percussion therapy, not assessment, involves tapping the flank area.