Elimination EAQ
Which medication turns urine reddish-orange in color?
Phenazopyridine
The client with a suprapubic prostatectomy for cancer of the prostate has continuous bladder irrigations (CBI) in place after surgery. Which primary goal is the nurse trying to achieve with the CBI?
Answer: Prevent the development of clots in the bladder. Reason: A continuous flushing of the bladder dilutes the bloody urine and empties the bladder, preventing clots. Fluid instilled into the bladder does not affect kidney function. Urinary output can be measured regardless of the amount of fluid instilled. The urinary retention catheter is not designed to exert pressure on the prostatic fossa.
Which dietary selections made by the client indicate understanding of previously taught dietary principles associated with having viral hepatitis?
Answer: Salad, sliced chicken sandwich, gelatin dessert
What would the nurse ask the mother of a child who goes to the bathroom almost every hour at school?
Answer: "Has your child been going to the bathroom often at home?" Reason: If this behavior persists outside school as well, the nurse may pursue a physical examination to test for possible problems such as a urinary tract infection or diabetes. Asking about a physical examination may eventually be done, but it is not the priority question. Frequent urination at home, not uncontrolled urination at night, is information that should be obtained from the parent first; enuresis can occur in boys even without a urinary tract infection. A short attention span is not related to the presenting problem.
A 20-lb infant has a normal saline enema ordered, at a dose of 10 mL/kg. Which dose would the nurse administer?
Answer: 90 mL Reason: First, the nurse must convert to kg by dividing 20/2.2 = 9.09 kg. 9.09 × 10 mL/kg = 90 mL dose to be administered.
The health care provider prescribes haloperidol 0.5 mg intramuscularly (IM). The haloperidol is available in a vial that contains 2 mg/mL. How much solution will the nurse administer?___ mL
Answer: 0.25mL Reason: The prescribed dose is 0.5 mg. The available concentration is 2 mg/mL. Use the dimensional analysis and/or ratio and proportion methods to determine how many milliliters the nurse would administer.
The nurse receives an order to prepare the solution for administering a cleansing enema to a 3-year-old child. Which is the volume of solution the nurse would prepare?
Answer: 250 to 350 mL Reason: The nurse would prepare 250 to 350 mL of warmed solution for administering a cleansing enema in a toddler. The nurse would prepare 150 to 250 mL of warmed solution for infants. In school-aged children, the volume of warmed solution is 300 to 500 mL. In adolescents, the volume required is 500 to 750 mL.
Which goal would the nurse expect a client receiving treatment for bacterial cystitis to achieve before their discharge from the hospital?
Answer: Achieve relief of clinical symptoms and maintain kidney function. Reason: Relief of symptoms and continued urine output are measurable responses to therapy and are the desired outcomes. Four liters of water per day is too much fluid; 2 to 3 liters a day is recommended to flush the bladder and urethra. Dietary restrictions are not necessary with cystitis. Bleeding is not a complication associated with this treatment.
The nurse administers vasopressin to a client and recalls that the medication is which type of hormone?
Answer: Antidiuretic hormone Reason: Vasopressin is an antidiuretic hormone. Somatotropin is a growth hormone. Gonadotropin is a luteinizing hormone. Thyrotropin is a thyroid-stimulating hormone.
Which statement indicates the nurse has a correct understanding of kidney ultrasonography?
Answer: "Kidney ultrasonography makes use of sound waves and has minimal risk." Reason: Kidney ultrasonography is a minimal-risk diagnostic procedure. Ultrasonography makes use of sound waves, which when reflected from internal organs of varying densities produce images of the kidneys, bladder, and associated structures on the display screen. Although a dye can be used in computed tomography (CT), it is not the primary method. Generally, when performing a kidney ultrasonography, the client's bladder is full. A CT scan gives three-dimensional information about the kidney and associated structures.
Which instruction would the nurse provide a client needing to collect a clean-catch urine specimen?
Answer: "Urinate a small amount, stop flow, and then fill one half of the specimen cup." Reason: Instruct the client to always collect midstream urine to send as a test specimen. Instruct the client to cleanse the perineum with the wipe provided, urinate a small amount, and then stop the flow. The client should then position the specimen cup a few inches from the urethra and resume urination, filling at least one half of the cup with urine. Instruct the client to collect the first sample voided in the morning because the urine is highly concentrated in the morning. Keeping the urine sample in the refrigerator helps reduce bacterial growth due to the urine's alkaline environment. The cells in the urine sample begin to break down in alkalinity; therefore instruct the client to send the sample to the laboratory as soon as possible after the collection.
Which is the maximum recommended length for enema tube insertion in an adolescent? Record your answer using a whole number. _____ cm
Answer: 10 cm Reason: In adolescents, the maximum length for insertion of an enema tube is 10 cm.
Which information would the nurse include when teaching about why women are more susceptible to urinary tract infections than men?
Answer: The length of the urethra Reason: The length of the urethra is shorter in women than in men; therefore microorganisms have a shorter distance to travel to reach the bladder. The proximity of the meatus to the anus in women also increases the incidence of urinary tract infections. Fluid intake may or may not be adequate in both men and women and does not account for the difference. Hygienic practices can be inadequate in men or women. Mucous membranes are continuous in both men and women.
The nurse prepares a male client with a history of recurrent urinary tract infections (UTIs) for discharge after a ureterolithotomy. Which clinical manifestations of a UTI would the nurse teach this client to recognize?
Answer: Urgency or frequency of urination Reason: Urgency or frequency of urination occurs with a urinary tract infection because of bladder irritability; burning on urination and fever are additional signs of a UTI. Increased ketones indicate diabetes mellitus, starvation, or dehydration. A UTI does not affect the ability of a male to maintain an erection. Pain radiating to the external genitalia is a symptom of a urinary calculus, not an infection.
Which assessment finding of a client with heart failure would prompt the nurse to contact the health care provider? Select all that apply. One, some, or all responses may be correct.
Answer: 4-pound weight gain, Dry hacking cough, Pitting edema, Orthopnea, Fatigue Reason: Signs of worsening heart failure include fatigue, weakness, and difficulty breathing when lying flat (orthopnea). Other manifestations include pitting edema, weight gain, and a dry, hacking cough.
Which factor would the nurse assess in a client reporting constipation? Select all that apply. One, some, or all responses may be correct.
Answer: Use of opioid pain medications, Date of last bowel movement, Use of laxatives, Fluid intake, Diet
Which is the recommended length of insertion of the enema tube in a child of 3 years?
Answer: 5 to 7.5 cm Reason: For a 3-year-old child, the recommended length of insertion of the enema tube is 5 to 7.5 cm. The length of 1 to 2.5 cm is incorrect, because it is too small. Even the insertion length of the enema tube used in infants is longer than this. For infants, the length of insertion of the enema tube should be 2.5 to 3.7 cm. For adolescents and adults, this length is 7.5 to 10 cm.
When preparing to administer medications safely, it is important for the nurse to remember at which age an infant's gastric emptying time reaches adult values?
Answer:6 to 8 months Reason: Gastric emptying is prolonged and irregular in early infancy. It gradually reaches adult values by 6 to 8 months of age. By the ages of 10 to 24 months, gastric emptying time will have already reached adult values.
Which conclusion would the nurse make about the assessment finding of a client's very pale-yellow-colored urine?
Answer:Dilute urine Reason: Dilute urine tends to appear very pale-yellow in color. Dark-red or brown color urine indicates hematuria, the presence of blood in the urine. Dark-amber color urine indicates concentrated urine. Red color urine may indicate the presence of myoglobinuria.
Which organ-specific autoimmune disorder would the nurse associate with a client's kidney?
Answer: Goodpasture syndrome Reason: Goodpasture syndrome is an autoimmune disorder associated with the client's kidney. Graves disease and Addison disease are autoimmune disorders associated with the endocrine system. Guillain-Barré syndrome is an autoimmune disorder associated with the central nervous system.
Which structure surrounding the male urethra would the nurse describe to a client scheduled for a dilation of the urethra?
Answer: Prostate gland Reason: The prostate gland is shaped like a ring, with the urethra passing through its center. The epididymis lies along the top and sides of the testes. The seminal vesicles are on the posterior surface of the bladder. The bulbourethral gland lies below the prostate.
Which instruction would the nurse include in a health practices teaching plan for a female client with a history of recurrent urinary tract infections?
Answer: "Wear cotton underwear or lingerie." Reason: Cotton allows air to circulate and does not retain moisture the way synthetic fabrics do; microorganisms multiply in warm, moist environments. Voiding frequently helps flush ascending microorganisms from the bladder, thereby reducing the risk for urinary tract infections; holding urine for more than 6 hours can lead to urinary tract infections. Foods high in acid, not alkaline ash, help acidify urine; this urine is less likely to support bacterial growth. Alkaline urine promotes bacterial growth. Wiping the genitals from back to front after toileting may transfer bacteria from the perianal area toward the urinary meatus, which will increase the risk for urinary tract infection.
Which is the recommended size of the urinary catheter that can be used in a 3-year-old child?
Answer: 8 to 10 Fr Reason: The recommended size of a urinary catheter that can be used in a 3-year-old child is 8 to 10 Fr. A urinary catheter of 5 to 6 Fr is generally used in infants. A length of 14 to 16 Fr is recommended for most adult clients. A length of 16 to 18 Fr is commonly used in adult males.
Which hormonal deficiency causes diabetes insipidus in a client?
Answer: Antidiuretic hormone (ADH) Reason: ADH deficiency causes diabetes insipidus. Decreased levels of prolactin may cause decreased amounts of milk secretion after birth. Decreased levels of thyrotropin cause hypothyroidism, weight gain, and lethargy. Luteinizing hormone deficiency causes menstrual abnormalities, decreased libido, and breast atrophy
A client is scheduled for discharge after surgery. The medical record indicates that the client has not had a bowel movement since before surgery, which was 4 days ago. Which prescribed medication will the nurse administer to ensure a bowel movement before discharge?
Answer: Bisacodyl suppository Reason: A bisacodyl suppository should produce results before the client leaves the facility; it usually takes effect in 15 to 60 minutes. Lactulose takes about 24 hours to take effect; docusate sodium takes 1 to 3 days; psyllium takes 12 to 24 hours.
A client had a colon resection and formation of a colostomy 2 days ago. Which color indicates to the nurse that the stoma is viable?
Answer: Brick red Reason: A brick red stoma indicates adequate vascular perfusion. A blue, gray, or dark purple color indicates inadequate perfusion of the stoma.
Which collecting structure is located at the end of the renal papilla?
Answer: Calyx Reason: The calyx is a cuplike structure that collects urine and is located at the end of each papilla. The outer surface of the kidney consists of fibrous tissue and is called the capsule. The renal cortex is the outer tissue layer. The renal columns are the cortical tissue that dip down into the interior of the kidney and separate the pyramids.
Which characteristic of urine changes in the presence of a urinary tract infection (UTI)?
Answer: Clarity Reason: Cloudy urine usually indicates drainage associated with infection. Viscosity is a characteristic that is not measurable in urine. Urinary glucose levels are not affected by UTIs. Specific gravity yields information related to fluid balance
Which component of the client's nephron acts as a receptor site for the antidiuretic hormone to regulate water balance?
Answer: Collecting ducts Reason: The collecting ducts regulate water balance and act as a receptor site for antidiuretic hormone. The Bowman capsule collects glomerular filtrate and funnels it into the tubule. The distal convoluted tubule acts as a site for additional water and electrolyte reabsorption. The proximal convoluted tubule is the site for reabsorption of sodium, chloride, water, and urea.
A client is taking fertility medications for the first time. Which adverse effect of the medication would the nurse inform the client about?
Answer: Constipation Reason: Constipation is seen in the clients who are treated with fertility medications for the first time. Fertility medications do not cause vaginitis or swelling of joints. Deep vein thrombosis is an adverse effect of prolonged use of fertility medications.
Which action would the nurse include in the plan of care for a client admitted with heart failure who has gained 20 pounds in 3 weeks? Select all that apply. One, some, or all responses may be correct.
Answer: Diuretics, Low-salt diet, Daily weight checks, Fluid restriction, Intake and output, Oxygen administration Reason: Interventions for a client with heart failure who has sustained a 20-pound weight gain would be focused on decreasing fluid retention. Interventions could include diuretic administration to increase fluid removal; a low-salt diet with fluid restriction; daily weight checks and measuring intake/output; and oxygen administration, particularly if the client has fluid in the lungs.
Why would lactulose be prescribed for a client with a history of cirrhosis of the liver?
Answer: Elevated ammonia levels are lowered. Reason: Lactulose is an ammonia detoxicant. It decreases serum ammonia concentration by preventing reabsorption of ammonia. Lactulose has been used to lower blood ammonia content in clients with portal hypertension and hepatic encephalopathy secondary to chronic liver disease. Lactulose has no effect on the craving for alcohol or reduction of ascites or abdominal distension. Lactulose is also used as a hyperosmotic laxative; therefore it will not relieve diarrhea.
Which type of cytokine is used to treat anemia secondary to chronic kidney disease?
Answer: Erythropoietin Reason: Cytokines are signaling cells. Erythropoietin is used to treat anemia related to chronic kidney disease. The failing kidneys are not able to produce erythropoietin to signal the bone marrow to produce red blood cells, resulting in anemia. α-Interferon is used to treat hairy cell leukemia or malignant melanoma. Interleukin-2 is used to treat metastatic renal carcinoma. Interleukin-11 is used to prevent thrombocytopenia after chemotherapy.
The nurse is caring for a client who is having diarrhea. Which client data would the nurse closely monitor to prevent an adverse outcome?
Answer: Fluid and electrolyte balance Reason: Monitoring fluid and electrolyte balance is the most important nursing intervention because excess loss of fluid through the multiple loose bowel movements associated with diarrhea lead to alteration in fluid and electrolyte imbalance. Although skin may become excoriated with diarrhea, this is not a life-threatening condition and is not the nursing priority. Even though absorption of nutrients is decreased with diarrhea malnutrition, it is not a life-threatening condition and is not the priority nursing intervention. Fluid intake and output provides information about fluid balance only, without taking into consideration the loss of electrolytes that accompanies diarrhea and is not the best choice.
Which surgical procedure involves urinary diversion in which the ureters are transplanted to a resected section of the small intestines, with one end attached to the abdominal wall?
Answer: Ileal conduit Reason: An ileal conduit is the transplantation of the ureters into a resected portion of the ileum, which is then used to create a stoma on the abdominal wall for drainage of urine. Cystostomy is an opening into the bladder through the abdominal wall that allows urine to flow out. In ureterosigmoidostomy, the ureter is transplanted into the colon and urine is excreted through the rectum. In cutaneous ureterostomy, the ureter is transplanted through the abdomen and attached to the skin.
A child with a history of nephrotic syndrome has a pale, muddy appearance; his appetite is poor; and he has been unusually tired after school. Which would the nurse suspect?
Answer: Impending renal failure Reason: The anemia associated with renal failure accounts for the pallor and decreased energy; the decreased appetite and decreased energy are related to the accumulation of toxic wastes. Excessive activity should not cause the signs and symptoms identified by the mother if the child is in remission. An increased temperature will probably be present with an infection; an infection does not cause a muddy pallor. Discontinuing the corticosteroids and diuretics, if prescribed, might result in a recurrence of edema in the steroid-dependent child; it is not a sign of renal failure.
For which condition would an infant born with exstrophy of the bladder be at risk?
Answer: Infection Reason: The greatest problem facing this infant is infection of the bladder mucosa and excoriation of the surrounding tissue; meticulous hygiene is necessary both before and after surgery. Dehydration is not a problem, because fluid intake and the amount of urine output are not affected. Urine retention is not a problem, because the urine drains continuously. The congenital abnormality involves the genitourinary system, not the intestines.
Which part of the kidney produces the hormone bradykinin?
Answer: Juxtaglomerular cells of the arterioles Reason: The juxtaglomerular cells of the arterioles produce the hormone bradykinin, which increases blood flow and vascular permeability. The kidney tissues produce prostaglandins that regulate internal blood flow by vasodilation or vasoconstriction. The kidney parenchyma produces erythropoietin that stimulates the bone marrow to make red blood cells. The renin-producing granular cells produce the renin hormone that raises blood pressure as a result of angiotensin and aldosterone secretion.
Which finding in a urinalysis indicates a urinary tract infection?
Answer: Leukoesterase Reason: Leukoesterases are released by white blood cells in response to an infection or inflammation. The presence of this chemical in urine indicates a urinary tract infection. The presence of crystals in the urine indicates that the specimen had been allowed to stand. Presence of bilirubin in the urine indicates anorexia nervosa, diabetic ketoacidosis, and prolonged fasting. The presence of ketones indicates diabetic ketoacidosis.
Which ovulation stimulant would the nurse identify as being derived from the urine of postmenopausal women?
Answer: Menotropins Reason: Menotropins are a standardized mixture of follicle-stimulating hormones and luteinizing hormones. These chemicals are derived from the urine of postmenopausal women. Clomiphene is a synthetic ovulation stimulant. Oxytocin and dinoprostone are synthetic uterine stimulants
A client hospitalized for uncontrolled hypertension and chest pain was started on a daily diuretic 2 days ago upon admission, with prescriptions for a daily basic metabolic panel. The client's potassium level this morning is 2.7 mEq/L (2.7 mmol/L). Which action will the nurse take next?
Answer: Notify the health care provider that the potassium level is below normal. Reason: The health care provider should be notified immediately because the client's potassium is below normal. The normal potassium level range is 3.5 mEq/L to 5.0 mEq/L (3.5-5.0 mmol/L). Clients on diuretic therapy require close monitoring of their electrolytes because some can cause hypokalemia, whereas others spare potassium, which can cause hyperkalemia. Retesting the serum potassium level is unnecessary and will delay the treatment required by the client.
Which primary symptom would the nurse assess for in a boy who has encopresis?
Answer: Passing feces either voluntarily or involuntarily into inappropriate places Reason: The primary symptom the nurse would observe in encopresis is passing feces either voluntarily or involuntarily into inappropriate places. Encopresis is the passage of feces into inappropriate places such as clothing, closets, floors, or toy boxes, either voluntarily or involuntarily. It may severely limit a child's social development and results in parental disapproval and rejection. Encopresis does not involve self-mutilation; self-mutilation occurs in borderline personality disorder. Encopresis does not involve self-induced vomiting; self-induced vomiting occurs with eating disorders. The passage of urine into inappropriate places is called enuresis
Which term is used to describe a client passing air and bubbles during urination?
Answer: Pneumaturia Reason: The occurrence of gas along with urination is called pneumaturia and could result from the formation of a fistula between the bowel and urinary bladder. Frequent urination during the night is called nocturia and is associated with conditions such as heart failure and diabetes mellitus. In medical conditions such as severe dehydration and shock, the urine output is reduced to 100 to 400 mL/day, and this is termed oliguria. Weak sphincter control, urinary retention, and estrogen deficiency are some causes for stress incontinence or involuntary urination during increased pressure situations.
The nurse providing postoperative care for a client who had kidney surgery reviews the client's urinalysis report. Which urinary finding indicates the need to notify the primary health care provider?
Answer: Presence of large proteins Reason: The glomeruli are not permeable to large proteins such as albumin or red blood cells, and finding them in the urine is abnormal; the nurse would report their presence to the primary health care provider to modify the client's treatment plan. The urine can be acidic; normal pH is 4.0 to 8.0. Glucose and bacteria should be negative and are normal findings.
Which nursing intervention would the nurse direct toward a child admitted for acute glomerulonephritis?
Answer: Promoting diuresis Reason: With the reduction of edema the child's health improves, the appetite increases, and the blood pressure normalizes. Ambulation does not have an adverse effect on this disorder; most children voluntarily restrict their activities and remain in bed during the acute phase. Fluids are not encouraged because the kidneys are inflamed and cannot tolerate large amounts of fluid. Sodium intake is decreased, not eliminated; sodium restriction is not tolerated well by children and may further decrease their appetite.
The nurse shares the discharge instructions with a client who has prostate cancer. The client asks, "How much more blood will they need? Don't they have enough?" Which laboratory test would the nurse discuss the need to monitor throughout the course of the disease?
Answer: Prostate-specific antigen (PSA) Reason: The PSA is an indication of the presence of prostate cancer; the higher the level, the greater the tumor burden. The health care provider will monitor the PSA levels throughout the course of the disease and periodically thereafter. Albumin is a protein and an indicator of nutritional and fluid status. Creatinine and BUN levels indicate renal function and may elevate when blockage of the urethra occurs from an enlarged prostate, but the reports do not indicate metastasis or prostate cancer.
The nurse is caring for a client who had a hip replacement 2 days prior. Which nursing intervention would the nurse perform next?
Answer: Provide perineal care. Reason: Providing perineal care helps preserve skin integrity for the client who is incapable of providing self-care. Turning and positioning the client who has decreased physical mobility after hip surgery is important in preventing skin breakdown, but it is not an immediate client need. Giving a complete bed bath is not necessary after each bowel movement because only the perineal area is typically soiled. Documenting the bowel movement should be done only after meeting immediate needs of the client.
Which part of the nephron secretes creatinine for elimination?
Answer: Proximal tubule Reason: The proximal tubule of the nephron secretes creatinine and hydrogen ions. It also reabsorbs water and electrolytes. The glomerulus filters the blood selectively. The ascending loop of Henle reabsorbs sodium and chloride, whereas the descending loop of Henle concentrates the filtrate. The collecting duct reabsorbs water.
Which statement explains why women have a greater risk for recurrent urinary tract infections than men do?
Answer: Proximity of the urethra to the anus Reason: Because a woman's urethra is closer to the anus than a man's is, the area has a greater risk for becoming contaminated. Urinary pH is within the same range in both men and women. Hormonal secretions have no effect on the development of bladder infections. The position of the bladder is the same in men and women.
For which additional defect would the nurse assess an infant with exstrophy of the bladder?
Answer: Pubic bone malformation Reason: The pubic bone and the bladder form during the same period of embryonic development. Imperforate anus, absence of a kidney, and congenital heart disease are not associated with exstrophy of the bladder.
Which action is promoted by vasopressin?
Answer: Reabsorption of water Reason: Vasopressin is also known as an antidiuretic hormone. It helps in the reabsorption of water into the capillaries. Aldosterone promotes sodium reabsorption. Natriuretic hormones promote tubular secretion of sodium. Erythropoietin stimulates bone marrow to make red blood cells.
The nurse is caring for a client with a bowel obstruction. Which assessment findings indicate the possible onset of peritonitis? Select all that apply. One, some, or all responses may be correct.
Answer: Rebound tenderness, Diminished bowel sounds, Rigid, boardlike abdomen Reason: Classic signs of peritonitis include abdominal rebound tenderness, diminished or absent bowel sounds, and a rigid, boardlike abdomen. The client will experience constipation, not diarrhea. The heart rate will be tachycardic
The nurse understands which vaccine may cause intussusception in children?
Answer: Rotavirus Reason: Rotavirus vaccines very rarely cause intussusception, a form of bowel obstruction in which the bowel telescopes in on itself. Hepatitis vaccines can cause anaphylactic reactions. The measles, mumps, and rubella vaccine may cause thrombocytopenia. The diphtheria, tetanus, and pertussis vaccine carries a small risk of causing acute encephalopathy, convulsions, and a shock-like state.
Which antidepressant may be prescribed to a new mother diagnosed with depression?
Answer: Sertraline Reason: Sertraline is considered safe in lactating females. Dosing immediately after breast-feeding can reduce the risk for excretion of the medication in the breast milk by the next feeding time. Fluoxetine and amphetamine are not recommended for breast-feeding clients. Carbamazepine is not used to treat depression.
Which electrolyte deficiency triggers the secretion of renin?
Answer: Sodium Reason: Low sodium ion concentration causes decreased blood volume, thereby resulting in decreased perfusion. Decreased blood volume triggers the release of renin from the juxtaglomerular cells. Deficiencies of calcium, chloride, and potassium do not stimulate the secretion of renin.
To ensure a quality specimen and an accurate test result, which instruction would the nurse give a client who is scheduled to undergo urine endocrine testing?
Answer: Store the urine specimen in a cooler with ice." Reason: The urine specimen that is collected for endocrine testing should be stored in a cooler with ice to prevent bacterial growth in the specimen. The nurse should instruct the client to start the urine collection after emptying the bladder. The client should be instructed not to store the urine specimen in a home refrigerator with other food and drinks because it could lead to cross-contamination. The client should be instructed to refrain from saving the urine specimen that begins the collection because the timing for urine collection starts from after the initial voiding specimen.
Which statement reflects the nurse's suspicions regarding a client's cloudy urine noted on a urinalysis report?
Answer: The client has a urinary infection. Reason: The urine becomes cloudy when an infection is present due to the presence of leukocytes. The nurse concludes the client has a urinary infection. In cases of biliary obstruction, the urine contains bilirubin. The presence of ketones in the urine indicates diabetic ketoacidosis or prolonged starvation.
A health care provider prescribes Lactobacillus granules to a 3-month-old infant to manage postantibiotic diarrhea. Which explanation would the nurse give to the infant's parents about the reason for giving lactobacilli?
Answer: The flora that inhabit a healthy gastrointestinal tract must be recolonized. Reason: Lactobacilli are part of the flora in the healthy gastrointestinal tract. The purpose of administering lactobacilli granules is to help recolonize the normal gastrointestinal flora that were destroyed with antibiotic therapy. The other options (diminishing mucosal edema, lessening discomfort from gastric hyperacidity, and pain relief from gas) are not the actions of lactobacilli granules.
Identify the type of hypersensitivity reaction associated with systemic lupus erythematosus (SLE).
Answer: Type III Reason: SLE is an example of an immune complex-mediated, or type III, hypersensitive reaction. Anaphylaxis is an example of a type I, or immediate hypersensitive reaction. Cytotoxic, or type II, hypersensitive reactions can result in conditions such as myasthenia gravis and Goodpasture syndrome. Graft rejection and sarcoidosis are conditions caused by delayed, or type IV, hypersensitivity reactions.
A client recovering from deep, partial-thickness burns develops chills, fever, flank pain, and malaise. Which prescribed diagnostic test would the nurse expect to confirm a tentative urinary tract diagnosis?
Answer: Urinalysis and urine culture and sensitivity Reason: The client's manifestations may indicate a urinary tract infection. A culture of the urine will identify the microorganism, and sensitivity will identify the most appropriate antibiotic. A cystoscopy is too invasive as a screening procedure; altered bilirubin results indicate liver or biliary problems, not urinary signs and symptoms. Creatinine clearance reflects renal function; A/G ratio reflects liver function. Although an increased urine specific gravity may indicate red blood cells, white blood cells, or casts in the urine, which are associated with urinary tract infection, it will not identify the causative organism.
