Exam 3: Practice Questions

The nurse is providing teaching to a middle-aged patient with heart failure. Which is the most important concept related to dietary management that the nurse should include? a. Reduce sodium intake b. Decrease fat intake c. Increase calcium intake d. Increase fluid intake

Reduce sodium intake

A patient reports urine leakage. The nurse notes the following medical history: obesity, ambulation difficulty, smoking, and hypertension treated with diuretics. Which lifestyle intervention should the nurse suggest to the patient to reduce urinary incontinence? a. Stopping all diuretics b. Decreasing activity c. Reducing physical barriers to toileting d. Switching from cigarette smoking to chewing tobacco

Reducing physical barriers to toileting

The nurse is caring for a patient diagnosed with acute pyelonephritis. The patient asks, "What exactly is this?" Which statement by the nurse is accurate? a. "Scarring of the renal tubules that occurs from prolonged inflammatory response." b. "A decrease in renal perfusion from changes in microscopic blood vessels." c. "An infection of the kidney that is caused by bacteria." d. "Inflammation of the ascending infection caused by the shrinking of the renal tubules."

"An infection of the kidney that is caused by bacteria."

A patient recently treated for a urinary tract infection (UTI) presents to the clinic. Significant findings include a temperature of 102.1° F (38.9° C) and flank tenderness. Which question asked by the nurse predominately relates to the clinical history and current assessment findings in the patient? a. "How much fluid did you drink in the past 24 hours?" b. "Did you finish your prescribed antibiotic for the UTI?" c. "Do you completely empty your bladder every 6 hours?" d. "Have you noticed any change in the color or odor of your urine?"

"Did you finish your prescribed antibiotic for the UTI?"

The nurse is evaluating a female patient's risk for bladder cancer. Which question should the nurse ask the patient? a. "Do you have multiple sexual partners?" b. "Do you use recreational drugs?" c. "Do you use bubble bath?" d. "Do you smoke cigarettes?"

"Do you smoke cigarettes?"

The nurse is evaluating a patient with stress incontinence due to weak pelvic floor muscles who continues to experience leakage. Which question should the nurse ask to investigate ongoing stress incontinence? a. "Have you been performing Kegel exercises?" b. "Are you having trouble ambulating?" c. "Have you increased your fiber intake?" d. "Have you decreased your fluid intake?"

"Have you been performing Kegel exercises?" RATIONALE: The nurse would investigate the use of Kegel exercises to strengthen the pelvic floor muscles in the patient with stress incontinence. Fluid intake would be investigated if timing with fluid intake and amount were the cause of incontinence. Fiber intake would be investigated in a patient with constipation. Ambulation issues would be indicated in the person with functional decline.

The nurse is interviewing an older adult with kidney stones. Which assessment question is asked to uncover a risk factor for kidney stones in the older adult? a. "Do you have a history of urinary tract infections?" b. "Are you on any diuretics?" c. "Have you ever been diagnosed with gout?" d. "Have you ever been prescribed medication to lower the calcium in your blood?"

"Have you ever been diagnosed with gout?"

The nurse is caring for an older adult who is reluctant to drink and holds their urine so that they do not have to get up often to the commode. The patient's daughter asks why their mother does not have a urinary catheter in place. Which response by the nurse provides the most accurate information? a. "Infections from urinary catheters often result in kidney infections, which may result in renal failure." b. "Having a urinary catheter in place would increase your mother's risk of developing a urinary tract infection." c. "The urinary catheter can reduce your mother's need to void, which could be a bigger problem later on." d. "Movement is easier without a catheter and encouraged so that additional complications do not occur."

"Having a urinary catheter in place would increase your mother's risk of developing a urinary tract infection."

The nurse is caring for a patient with peripheral atherosclerosis. Which report from the patient is most important for the nurse to know about? a. "My legs start to hurt when I walk a lot." b. "I have started using slippers for when I get out of bed." c. "I have a cut and a bad bruise on the top of my foot that still hurts." d. "I have some pain in my legs when I sleep at night."

"I have a cut and a bad bruise on the top of my foot that still hurts."

The nurse is reviewing the chart of a patient diagnosed with pyelonephritis. Which subjective statement should the nurse anticipate from the patient related to the pathophysiological changes of pyelonephritis? a. "It burns when I urinate." b. "I woke up and realized I'd accidentally wet the bed." c. "I have been vomiting for the last few days." d. "I feel like I need to urinate constantly."

"I have been vomiting for the last few days."

A patient is completing a health history questionnaire. Which patient response should indicate the need to assess for peripheral atherosclerosis? a. "I have hairless lower legs." b. "My toenails are thin and brittle." c. "My legs are dark red when elevated." d. "I have strong peripheral pulses in both legs."

"I have hairless lower legs."

The nurse is teaching a patient with atherosclerosis about their condition. Which patient statement indicates the teaching was successful? a. "There is plaque building up in my femoral artery, which is restricting the blood flow to my heart." b. "I have plaque building up in my coronary arteries, which is restricting the blood flow to my heart." c. "Plaque is building up in my heart vessel valves, which is restricting the blood flow to my heart." d. "Plaque is building up in my pulmonary artery, which is restricting blood flow to my heart."

"I have plaque building up in my coronary arteries, which is restricting the blood flow to my heart."

The nurse is evaluating a patient diagnosed with coronary artery disease (CAD) for the development of an acute myocardial infarction (AMI). Which patient statement indicates to the nurse the development of unstable angina? a. "I'm having tight, squeezing pain in my chest every day. When I sit to rest, it goes away, but comes back when I work. " b. "I get a sudden spasming pain in my chest that radiates down my arm and goes away quickly no matter what I'm doing. Sometimes it occurs while I'm sitting." c. "I have pain in my chest and jaw every night when I lie down. When I sit up, it usually goes away." d. "I seem to be having pain more frequently, and it doesn't matter what I'm doing. It is usually very painful, makes me sweaty, and even occurs while I am resting."

"I seem to be having pain more frequently, and it doesn't matter what I'm doing. It is usually very painful, makes me sweaty, and even occurs while I am resting."

The nurse is teaching a patient about a potassium-sparing diuretic drug. Which patient statement indicates that the teaching is successful? a. "This medication will lower blood pressure by increasing blood volume." b. "I can continue to use salt substitutes." c. "This medication will decrease my urine output." d. "I should change positions slowly."

"I should change positions slowly."

The nurse instructs a patient on actions to prevent the development of bladder cancer. Which patient statement should indicate to the nurse that teaching was effective? a. "I should avoid bubble baths." b. "I should eat more fruits and vegetables." c. "I should avoid alcohol." d. "I should drink more fruit juices."

"I should eat more fruits and vegetables." RATIONALE: Teaching to prevent bladder cancer includes increasing the intake of fruits and vegetables. Alcohol does not need to be avoided. Fruit juice and bubble baths contribute to the development of urinary tract infections however have no impact on the development of bladder cancer.

The nurse provided preoperative teaching to a patient who is scheduled for a coronary artery bypass graft using the internal mammary artery. Which patient statement indicates that additional teaching is needed? a. "My blood will be circulated by a machine during surgery." b. "They will bypass the clogged artery near my heart by using an artery to get blood flowing around the blockage." c. "I will need to take medication every day after the surgery to make sure the graft stays open." d. "I will have a scar on my leg from where they remove the vein."

"I will have a scar on my leg from where they remove the vein."

The nurse is monitoring a patient who is ambulating after a recent coronary artery bypass graft (CABG) procedure. The patient is nervous about how much activity they will be able to tolerate and is reluctant to exercise. Which statement by the nurse will help the patient? a. "You can stop if your oxygen level drops below 98% or if you feel winded." b. "I will count your respiratory rate while you are walking. If it increases over 18 breaths per minute, I will stop you." c. "I will have you rest if your blood pressure rises while you are walking." d. "I will stop you if your heart rate increases more than 20 beats per minute over your resting rate."

"I will stop you if your heart rate increases more than 20 beats per minute over your resting rate."

A patient diagnosed with a urinary tract infection provides a urine sample for culture and sensitivity. The patient asks, "I know I have an infection, so why do you have to do this test?" Which is an accurate response by the nurse? a. "Bacteria and blood cells can be identified in the urine." b. "The test can identify the changes associated with the infection." c. "The test provides an evaluation of kidney function." d. "It enables your healthcare provider to choose an effective antibiotic."

"It enables your healthcare provider to choose an effective antibiotic."

A patient with peripheral vascular disease (PVD) states, "I want to stay active, but I am having a hard time getting motivated because every time I try to exercise my legs hurt." How should the nurse respond? a. "It is best to rest with your condition. You will always have pain with activity and you should avoid activity as much as possible." b. "It is best to maintain activity with your condition. You should continue activity if you have pain to increase your endurance." c. "It is best to rest with your condition. Once the peripheral vascular disease is treated, then you can start a moderate exercise program." d. "It is best to maintain activity with your condition, but make sure to rest if you develop pain during activity."

"It is best to maintain activity with your condition, but make sure to rest if you develop pain during activity."

q. The nurse is monitoring a patient who has recently had a percutaneous transluminal coronary angioplasty. Which patient statement indicates the need for immediate action by the nurse? a. "My last nurse said my blood pressure is 103/54 mmHg." b. "My heart is racing like crazy." c. "My leg is sore. How soon can I move it?" d. "My chest is burning, and it feels very tight, like I'm being crushed."

"My chest is burning, and it feels very tight, like I'm being crushed."

A patient diagnosed with a large renal calculus is being prepped for extracorporeal shock wave lithotripsy (ESWL). The patient asks the nurse where the incision will be made during the procedure. Which response by the nurse is accurate? a. "No incision is made. Shock waves are generated outside the body to break apart the stones." b. "The incision is made over the flank area for stone removal." c. "The incision is made just above the bladder in order to remove the stone." d. "No incision is made. This procedure is done simply to locate the stone for removal."

"No incision is made. Shock waves are generated outside the body to break apart the stones."

The nurse is preparing discharge instructions for a patient prescribed warfarin for a deep venous thrombosis. Which instruction should the nurse include? a. "Take the warfarin at bedtime each day." b. "Notify the healthcare provider of bleeding or bruising." c. "Use a hard-bristle toothbrush." d. "Omit warfarin on the days when laboratory tests are ordered."

"Notify the healthcare provider of bleeding or bruising."

The nurse is teaching a patient with renal calculi about the importance of pain management. The patient asks what causes the severe pain. Which response by the nurse is accurate? a. "Pain is quite severe when the kidney stone is located in the bladder." b. "Pain is caused by the acidic urine associated with kidney stones." c. "Pain is caused by the kidney stone scraping against the lining of the tube that connects the kidney to the bladder." d. "Pain is the result of excess fluid pushing inside the tube that connects the kidney to the bladder."

"Pain is caused by the kidney stone scraping against the lining of the tube that connects the kidney to the bladder."

A patient is being discharged to home with a diagnosis of renal calculi. The patient has not passed any stones during admission. Which instruction is important to include in the discharge teaching? a. "Increase dietary calcium and vitamin D to prevent stone formation." b. "You do not have to come if you experience this again because it will resolve as this one did." c. "Strain all urine for stones. If one is found, call your healthcare provider and bring it in for analysis." d. "Limit fluid intake to eight, 8-oz glasses of water for the next week."

"Strain all urine for stones. If one is found, call your healthcare provider and bring it in for analysis."

The nurse is teaching a patient about medications to increase blood flow to the coronary arteries. Which statement should the nurse include? a. "Taking acetylsalicylic acid daily may help improve blood flow in your coronary arteries." b. "Taking an anti-inflammatory every day can help to increase blood flow to your heart." c. "You should take a pain-relieving analgesic daily to control your chest pain." d. "You should not take any statins."

"Taking acetylsalicylic acid daily may help improve blood flow in your coronary arteries."

The nurse is administering a urinary analgesic for pain associated with a UTI. The patient asks the nurse, "How will this help my pain?" Which response by the nurse is accurate? a. "The medication will decrease the inflammation and reduce the irritation you are feeling." b. "The medication will decrease the pain in your kidneys." c. "The medication will help flush out the bacteria causing the infection." d. "The medication will cause numbness in the bladder so you will not feel pain."

"The medication will decrease the inflammation and reduce the irritation you are feeling."

The patient with a resolved ureteral calculi asks, "How can I prevent this from happening again?" Which is the nurse's best response? a. "Make sure you empty your bladder frequently." b. "The most effective prevention is adequate fluid intake." c. "Avoid eating meat and nuts." d. "Increase your daily consumption of cranberry juice."

"The most effective prevention is adequate fluid intake."

An older adult patient asks why urine leaks when walking to the bathroom. Which response should the nurse make? a. "The diuretics that you take cause you to retain urine." b. "You have a lower level of a hormone that makes it hard for you to control urination." c. "The bladder muscles get stronger over time, making it difficult for you to relax for urination." d. "The muscles under your bladder become weakened with age, making it difficult to control urine flow."

"The muscles under your bladder become weakened with age, making it difficult to control urine flow."

The nurse is caring for a patient with peripheral vascular disease (PVD) who reports burning pain in the legs at night in bed. Which response by the nurse is appropriate? a. "This is known as rest pain. Dangling your legs off your bed may help your pain." "b. This is known as intermittent claudication. Wearing compression socks to bed may help your pain." c. "This is known as rest pain. Elevating your legs may help your pain." d. "This known as intermittent claudication. Elevating your legs may help your pain."

"This is known as rest pain. Dangling your legs off your bed may help your pain."

A patient with urinary incontinence is scheduled for bladder stress testing. The patient's family asks the nurse, "What is this test for?" Which response by the nurse is accurate? a. "This test will determine how completely the bladder empties with voiding." b. "This test will evaluate detrusor muscle function." c. "This test will measure how much urine leakage occurs with coughing." d. "This test will identify structural disorders contributing to incontinence."

"This test will measure how much urine leakage occurs with coughing."

An older male with urinary problems asks why a bladder scan is needed. Which response should the nurse make? a. "To see how much pressure is in the urethra" b. "To look at how much urine is passed per second. c. "To look for bladder infection" d. "To see how much you empty your bladder"

"To look for bladder infection"

The nurse caring for a patient with a history of urinary tract infections (UTIs) states that vesicoureteral reflux is suspected as the causative factor. Which statement by the nurse further explains this? a. "Vesicoureteral reflux involves backflow of urine from the bladder back into your kidneys." b. "Vesicoureteral reflux is a result of an accumulation of urine that has flowed back into your kidneys." c. "Vesicoureteral reflux results because you do not voluntarily completely empty your bladder." d. "Vesicoureteral reflux is a condition where bladder spasms cause irritation of the lining of your bladder."

"Vesicoureteral reflux involves backflow of urine from the bladder back into your kidneys."

A patient is scheduled for a cardiac catheterization. Which teaching should the nurse provide to the patient before the test? a. "You cannot have any food or fluids for 6 to 8 hours before the test." b. "You cannot have this test if you are allergic to seafood or iodine." c. "The test will take up to 6 hours to complete." d. "You can drive home after the test."

"You cannot have any food or fluids for 6 to 8 hours before the test."

An older patient reports daily exercise but needs longer periods of rest between activities. Which response should the nurse make? a. "Your heart rate increases with the activities, but it takes longer to return to your normal rate than it did when you were younger. This results in your needing longer rest periods between activities." b. "Your blood pressure drops when you stop the activity. As a result, it takes longer for your blood pressure to rise than it did when you were younger. Therefore, you need longer rest periods between activities." c. "The amount of blood you pump through your heart during exercise is greater than when you are at rest. This amount increases as you get older, requiring you to rest more between activities." d. "Your pulse rate increases during activities. As you get older, this increase lessens, causing you to become more tired during activities. This requires that you rest for longer periods of time between activities."

"Your heart rate increases with the activities, but it takes longer to return to your normal rate than it did when you were younger. This results in your needing longer rest periods between activities."

The nurse is assessing several patients. Which patient should the nurse identify as being at the greatest risk for developing hypertension? a. A 72-year-old Asian patient who exercises twice a week b. A 42-year-old White patient who drinks one glass of red wine twice a week c. A 46-year-old Black patient who exercises daily and drinks four glasses of red wine daily d. A 65-year-old Black patient with insulin resistance

A 65-year-old Black patient with insulin resistance

A patient is scheduled for a transesophageal echocardiography (TEE). Which should this patient receive before the test? a. A sedative b. Clear liquids c. Injection of radioactive medium d. A dose of an antibiotic

A sedative

A nurse is caring for a client who experienced defibrillation. Which of the following should be included in the documentation of this procedure? (SATA) a. Follow-up ECG b. Energy settings used c. IV fluid intake d. Urinary output e. Skin condition under electrodes

A, B, E

The nurse is assessing heart sounds in a patient. Which physiologic action should occur when auscultating the S1 (lub) sound? a. Atrioventricular (AV) and mitral valves close b. Aortic and mitral valves close c. Pulmonic and aortic valves close d. Semilunar valves close

Atrioventricular (AV) and mitral valves close

The nurse is assessing an older female patient. Which observation should the nurse include to help determine if the patient is experiencing urinary incontinence? a. Asking the patient directly about incontinence issues b. Palpating the bladder and noting any leakage c. Assessing for the odor of urine d. Checking the odor of the patient's underwear

Assessing for the odor of urine RATIONALE: The presence of an odor of urine could indicate urinary incontinence. Checking the patient's underwear is rather invasive and not appropriate to do. Asking about incontinence may not provide correct information because the patient may be embarrassed to admit the problem. Palpating the bladder to look for leakage is not a valid assessment technique.

A patient is scheduled for a renal arteriogram. Which should the nurse assess the patient before this diagnostic test? a. Taking anticoagulants as prescribed b. Breakfast of clear liquids c. Allergy to seafood d. Taking oral hypoglycemic agents as prescribed

Allergy to seafood

A 63-year-old marathon runner was admitted to the hospital with chest pain. The nurse notices that the patient is asleep and the cardiac monitor is showing sinus bradycardia with a heart rate of 54 beats/min. The patient's blood pressure is 122/82 mmHg, and pulse oximeter is reading 99%. Which nursing action is most appropriate? a. Obtaining a 12-lead electrocardiogram (ECG) b. Allowing the patient to continue sleeping c. Notifying the healthcare provider d. Starting cardiopulmonary resuscitation

Allowing the patient to continue sleeping

The nurse is discussing risk factors for coronary artery disease with a colleague. Which statement describes the impact of chronic hypertension on the patient's vascular system? a. Increased laminar flow through vessels b. Decreased likelihood for thrombus formation c. Consistent blood pressure measurement d. Alters the endothelium leading to increased release of chemical mediators

Alters the endothelium leading to increased release of chemical mediators RATIONALE: Chronic hypertension leads to altered permeability of the vascular endothelium, thereby causing injury and inflammation, which in turn leads to increased potential for thrombus formation and disruption of laminar flow. As the endothelial lining becomes more damaged, blood pressure will continue to rise in an attempt to increase the force of blood through vessels.

If a patient has a pressure ulcer, what are the tree main priorities?

Give medications Debridement Hyper chamber

The nurse wants to determine a patient's mean arterial pressure (MAP). Which measurement should the nurse use to make this calculation? a. Blood pressure (BP) b. Heart rate c. Body surface area (BSA) d. Basal metabolic rate (BMR)

Blood pressure

The nurse is caring for a patient who reports intermittent palpitations with lightheadedness. The electrocardiogram (ECG) shows normal sinus rhythm. Which collaborative intervention should the nurse plan for that would help to diagnose the dysrhythmia? a. Exercise test b. 12-lead ECG c. Echocardiogram d. Holter monitor

Holter monitor

A patient had a bypass graft nd is in post op, what does the nurse do?

Check temp, pulses, color, cap refil, if the patient can move their toes

Which factor should the nurse include as a bladder irritant when teaching a patient with UTI? a. Low-sugar cranberry juice b. Citrus juices c. Mineral water d. Foods high in oxalate

Citrus juices

The nurse is reviewing the anatomy of the kidney. Which region should the nurse identify that contains nephrons? a. Cortex b. Medulla c. Pelvis d. Pyramids

Cortex The renal cortex contains the nephrons which are the functional units of the kidney. The medulla contains the renal pyramids which are collecting tubules. The pelvis is the innermost part of the kidney and is continuous with the ureter.

A patient is scheduled for a serum creatinine test. Which should the nurse instruct the patient to avoid the day before the test? a. Alcohol b. Red meat c. Water d. Vegetables

Red meat

An older patient reports routine physical activities. Which should the nurse consider as a reason for the patient needing to rest between activities? a. Decreased cardiac output resulting in longer period of tacycardia b. Lower blood pressure due to decreased cardiac output c. Decreased stroke volume related to exercise d. Decreased pulse to compensate for change in stroke volume

Decreased cardiac output resulting in longer period of tacycardia

A female patient has a history of urinary tract infections (UTIs). Which should the nurse instruct the patient to reduce the risk of another infection? a. Drink 2 to 2.5 quarts of water each day b. Drink two glasses of orange juice every day c. Use a vaginal spray to control odor d. Empty the bladder every 6 hours

Drink 2 to 2.5 quarts of water each day

The nurse is providing care to a patient diagnosed with urinary urgency. The healthcare provider prescribes an anticholinergic medication to increase bladder capacity and inhibit bladder contractions for the patient. Which finding would alert the nurse to an adverse effect resulting from the anticholinergics? a. Decrease in blood pressure b. Diarrhea c. Increased urinary output d. Dry mouth

Dry mouth

A patient is diagnosed with anemia. Which hormone should the nurse expect to be activated in this patient? a. Antidiuretic hormone b. Vitamin D c. Erythropoietin d. Natriuretic hormone

Erythropoietin

T/F: Arterial ulcers are more superficial than venous ulcers.

False. Arterial ulcers are deeper and venous ulcers are more superficial.

A patient is recovering from a cystoscopy. Which should the nurse instruct the patient to report to the healthcare provider? a. Flank pain b. Blood in the urine when voiding for the first time c. Abdominal muscle spasms d. Burning with urination

Flank pain RATIONALE: After a cystoscopy the patient may experience burning with urination for a day or two. Blood may be in the urine for up to three voidings. Abdominal muscle spasms can be treated with an application of heat. Flank pain should be reported to the healthcare provider.

The nurse is caring for a patient who reports intermittent palpitations with lightheadedness. The electrocardiogram (ECG) shows normal sinus rhythm. Which collaborative intervention should the nurse plan for that would help to diagnose the dysrhythmia? a. 12-lead ECG b. Holter monitor c. Echocardiogram d. Exercise test

Holter monitor RATIONALE: Holter monitor is used to identify intermittent dysrhythmias. The patient wears a Holter monitor for an extended period, and the monitor records the dysrhythmia each time it happens. A 12-lead ECG, an echocardiogram, or an exercise test will not identify intermittent dysrhythmias, as these tests are not performed over an extended period.

The nurse is assessing a patient with a history of urinary retention who is diagnosed with a urinary tract infection. When reviewing the patient's health history, which finding would most likely be the causative agent? a. Lack of performing Kegel exercises b. Alzheimer disease c. Decreased functional mobility d. Intermittent self-catheterization

Intermittent self-catheterization RATIONALE: A patient performing intermittent self-catheterization would be at high risk for the development of a urinary tract infection due to the introduction of a foreign object into the sterile urinary tract. Lack of performing Kegel exercises, difficulty ambulating, and Alzheimer disease cause urinary incontinence, not retention and infection.

The nurse is caring for a patient diagnosed with acute renal colic. The patient rates the pain at 8 on a 0-10 scale. Which medication should the nurse expect to administer to address the patient's pain? a. Diuretic b. Intravenous narcotic c. The oral narcotic hydrocodone d. Urinary alkalinizer

Intravenous narcotic

A patient is experiencing low blood pressure. Which part of the kidney should the nurse suspect is malfunctioning in this patient? a. Medulla b. Juxtaglomerular apparatus c. Cortex d. Pelvis

Juxtaglomerular apparatus RATIONALE: A sustained drop in systemic blood pressure triggers the juxtaglomerular cells to release renin. Renin acts on a plasma globulin, angiotensinogen, to release angiotensin I, which is in turn converted to angiotensin II. As a vasoconstrictor, angiotensin II activates vascular smooth muscle throughout the body, causing systemic blood pressure to rise. The cortex, medulla, and pelvis do not play a role in blood pressure control.

The nurse asks a patient to sit upright on the side of the examination table. Which genitourinary structure should the nurse palpate with the patient in this position? a. Penis b. Bladder c. Scrotum d. Kidneys

Kidneys

A patient with coronary artery disease is leaving the hospital to go home. Which aspect of home care should be of greatest focus in the nurse's teaching for this patient? a. Safety concerns b. Return to normal activity c. Lifestyle changes d. Follow-up care

Lifestyle changes

The nurse is reviewing the lymphatic system for a patient with lower extremity edema. Which should the nurse include in this explanation? a. Lymph transport depends on muscle contraction. b. Valves help lymph return to the circulation. c. Lymph structures contain only one layer of cells. d. Lymph movement depends on blood flow, peripheral vascular resistance (PVR), and blood pressure (BP)

Lymph transport depends on muscle contraction

A patient has a low glomerular filtration rate (GFR). Which should the nurse identify that is affecting this late? a. Number of functioning nephrons b. Fluid balance c. Protein intake d. Blood pressure

Number of functioning nephrons

The nurse is preparing to perform a physical examination on a patient suspected to have pyelonephritis. Which physical assessment should the nurse perform? a. Percuss for costovertebral tenderness. b. Palpate for suprapubic tenderness. c. Obtain a urinalysis. d. Examine the shape and contour of the abdomen.

Percuss for costovertebral tenderness. RATIONALE: Costovertebral tenderness is an assessment used to help diagnose kidney pathology. A patient with pyelonephritis will have tenderness in the area of percussion and palpation. A urinary tract infection (UTI) is associated with suprapubic tenderness. A urinalysis is a laboratory test that can be utilized with physical assessment findings to confirm the presence of pyuria, bacteria, and blood cells in the urine. The shape and contour of the abdomen is not an indicator of pyelonephritis.

A patient is diagnosed with atherosclerotic plaque in the coronary arteries. Which statement about coronary plaque is correct? a. Plaque remains asymptomatic and causes no change in coronary oxygenation. b. Plaque is a stable narrowing that can be resolved with diet changes. c. Plaque in the coronary arteries causes collateral circulation that will prevent damage to the heart. d. Plaque is at risk for rupture that could result in occlusion of the artery.

Plaque is at risk for rupture that could result in occlusion of the artery.

The nurse plans care for a patient with a urinary problem. For which reason should the nurse establish a voiding schedule for this patient? a. Prevent urinary incontinence b. Enhance kidney functioning c. Prevent urinary retention d. Enhance bladder tone

Prevent urinary incontinence

The nurse is caring for a patient with ureteral calculi. Which clinical assessment finding should the nurse anticipate? a. Bilateral flank pain b. Renal colic c. Pyuria d. Increased urinary output

Renal colic RATIONALE: The predominant clinical assessment finding associated with ureteral calculi is renal colic. Further clinical manifestations of ureteral calculi include acute, severe flank pain on affected side (not bilaterally) and the likelihood of pain radiating to the suprapubic region, groin, and external genitals. The pain causes the sympathetic response of nausea; vomiting; pallor; and cool, clammy skin. Increased urinary output is not a manifestation of ureteral calculi. Pyruria would generally not be present without concurrent infection.

A patient has edema of the face, fingers, and feet. Which health problem should the nurse associate with these findings? a. Prostate disease b. Bladder cancer c. Epididymitis d. Renal disease

Renal disease

A patient's urine specific gravity is 1.001. Which action should the nurse take? a. Prepare to administer antibiotics b. Restrict fluids c. Restrict the intake of foods containing potassium d. Report the finding to the healthcare provider

Report the finding to the healthcare provider RATIONALE: A specific gravity of less than 1.005 can indicate diabetes insipidus, overhydration, renal disease, or a severe potassium deficit. The finding of 1.001 should be reported to the healthcare provider. Restricting fluids could make the specific gravity become lower. Potassium-containing foods should not be restricted until the reason for the low specific gravity is determined. A low specific gravity does not indicate an infection or the need for antibiotics.

The nurse is caring for a patient with renal colic and acute, severe, right-sided flank pain. Where should the nurse suspect the urinary calculi are located? a. Bladder b. Right ureter c. Urethra d.Kidney

Right ureter

The nurse is reviewing the physiologic actions associated with heart sounds. Which heart sound should the nurse hear when the atrioventricular (AV) and mitral valves close? a. S1 b. S2 c. S3 d. S4

S1

The nurse is performing a cardiovascular assessment on a patient. Which structure should the nurse locate after palpating the junction of the manubrium and the sternum? a. Second intercostal space (ICS) b. False ribs c. Right midclavicular line d. Xiphoid process

Second intercostal space (ICS)

A patient is diagnosed with renal calculi. Which specific laboratory test should the nurse expect to be most likely elevated? a. Serum calcium b. Potassium c. Creatinine d. Cholesterol

Serum calcium

A patient is experiencing problems with urinary elimination. Which specific assessment should the nurse include during the physical assessment? a. Perianal b. Nutrition c. Inguinal area d. Skin

Skin RATIONALE: A focused nursing assessment of the urinary system includes a skin assessment, an abdominal assessment, a urinary meatus assessment, a kidney assessment, and a bladder assessment. Nutritional, perianal, and inguinal area assessments would be appropriate for a patient experiencing an alteration in bowel function.

Which finding in the patient's history should the nurse know is a risk factor for bladder cancer? a. Smoking b. Prostate cancer c. Kidney stone d. Cervical cancer

Smoking

The nurse is reviewing the results of a patient's urinalysis. Which finding should the nurse report to the healthcare provider? a. Protein 2 mg/dL b. Specific gravity less than 1.005 c. Ammonia odor d. pH 7.0

Specific gravity less than 1.005

The nurse is assessing a female patient. Which area should be inspected to assess bladder distention? a.Labia majora b. Mons pubis c. Suprapubic area d. Urethral opening

Suprapubic area RATIONALE: Bladder distention may be visualized by inspecting the suprapubic area, because the distended bladder would rise above the symphysis pubis. The mons pubis is inspected for hair distribution and signs of puberty development. The urethral opening is inspected for inflammation and signs of infection. The labia majora are inspected for lesions and rashes that may indicate infection or sexually transmitted diseases.

The nurse auscultates a patient's abdomen. Which finding should the nurse identify is related to the urinary system? a. Gurgling over the umbilicus b. Swishing sound heard on one or both sides of the abdomen c. High-pitched sounds across the abdomen d. Absence of sound

Swishing sound heard on one or both sides of the abdomen

An older adult patient is in ventricular tachycardia (VT). The patient is awake but is short of breath with a low normal blood pressure. Which collaborative treatment should the nurse anticipate will be used to interrupt the ventricular tachycardia? a. Synchronized cardioversion b. Asynchronous pacing c. Defibrillation d. Overdrive pacing

Synchronized cardioversion

A nurse is discussing dietary changes with a patient who has coronary artery disease. Which nursing intervention is most appropriate for this patient? a. Giving the patient a list of low-sodium, low-cholesterol foods b. Teaching the patient to adapt their favorite high-fat recipes by using monounsaturated oils when possible c. Advising the patient that not making the necessary changes puts them at increased risk for additional heart problems d. Providing the patient with a nutrition guide for reference

Teaching the patient to adapt their favorite high-fat recipes by using monounsaturated oils when possible

A patient asks how the kidneys impact blood pressure. Which explanation should the nurse provide? a. The kidneys produce renin, an enzyme that helps regulate blood pressure. b. The kidneys produce erythropoietin, a hormone that controls blood pressure. c. The kidneys excrete nitrogen wastes that control blood pressure. d. The kidneys metabolize vitamins that assist in the management of blood pressure.

The kidneys produce renin, an enzyme that helps regulate blood pressure.

The nurse is assessing an older adult patient who is disoriented and reports dizziness. Which finding suggests that the disorientation is caused by an acute myocardial infarction? a. The patient has difficulty breathing and weak pulses. b. The patient is slurring their speech. c. The patient has trouble walking. d. The patient's muscles are stiff on the left side.

The patient has difficulty breathing and weak pulses.

The nurse is assessing a woman who has had persistent heartburn, fatigue, and weakness of the upper arms. Which finding suggests that the pain is caused by an acute myocardial infarction (AMI)? a. The patient has nausea and shortness of breath. b. The patient has pain in their upper right quadrant radiating to the back. c. The pain increases when the patient takes a deep breath. d. The pain is reproducible when the patient raises their arms.

The patient has nausea and shortness of breath.

While making rounds on assigned patients, the nurse notes an ampule of vitamin K at the bedside of one patient. Which should the nurse understand from the presence of this medication? a. The patient is receiving low molecular weight heparin injections. b. The patient is receiving high-dose aspirin therapy. c. The patient is receiving intravenous heparin. d. The patient is receiving warfarin.

The patient is receiving warfarin.

The nurse is caring for a patient with urinary incontinence who has been prescribed bladder-training behavior modification. Which goal of therapy should the nurse include in the teaching session with the patient? a. To toilet on a schedule that corresponds with the normal pattern b. To improve pelvic floor muscle strength by stopping the urine flow during voiding and holding for a few seconds c. To gradually increase the bladder capacity by increasing the intervals between voiding and resisting the urge to void between scheduled times d. To toilet at regular intervals (e.g., every 2-4 hours)

To gradually increase the bladder capacity by increasing the intervals between voiding and resisting the urge to void between scheduled times

A 57-year-old man arrives in the emergency department reporting persistent chest pain for the last 48 hours. The chest pain is rated as a 7 on a 10-point scale, and it radiates up the patient's neck. Which laboratory values are the most important for the nurse to monitor? a. BMP, CPK, and troponin b. CBC and CPK c. PTT, CBC, and CK-MB d. Troponin, CPK, and CK-MB

Troponin, CPK, and CK-MB

The nurse notes in the medical record that the patient's incontinence is related to an overactive detrusor muscle. Which type of urinary incontinence should the nurse suspect the patient is experiencing? a. Overflow b. Stress c. Urge d. Functional

Urge RATIONALE: Urge incontinence is related to an overactive detrusor muscle, which increases bladder pressure. Stress incontinence is related to pelvic muscle relaxation and a weak urethra and surrounding tissues, which cause decreased urethral resistance. Overflow incontinence is related to a lack of normal detrusor muscle function, which causes the bladder to overfill and increases bladder pressure. Functional incontinence is related to the inability to respond to the need to urinate.

A patient diagnosed with a urinary tract infection (UTI) reports the pain at 7 on a 0-10 scale. Which drug classification should the nurse expect to find on the medication administration record (MAR)? a. Sulfonamide antibiotics b. Penicillin antibiotics c. Glycopeptide antibiotics d. Urinary analgesic

Urinary analgesic

The nurse is preparing a presentation on urinary elimination problems for a group of older adults. Which information should the nurse include? a. Very few men experience urinary incontinence after treatment for enlarged prostate. b. Urinary retention is common. c. Very few women complain of urinary incontinence. d. A majority of men report moderate to severe lower urinary tract symptoms.

Urinary retention is common. RATIONALE: Urinary retention is a common occurrence with aging. This is because the muscles weaken and bladder capacity decreases. Issues with urinary incontinence associated with treatment for an enlarged prostate are common. Severe lower urinary tract symptoms is not a common occurrence in men. Many women experience incontinence or lower urinary tract symptoms.

The results of a patient's urinalysis state the urine is cloudy. Which diagnosis should the nurse anticipate based on this finding? a. Urinary tract infection b. High blood glucose levels c. Cirrhosis of the liver d. Dehydration and fever

Urinary tract infection

A patient is diagnosed with glomerulonephritis. Which should the nurse anticipate when assessing this patient? a. Validation of oliguria b. Symptoms of dysuria c. Experiencing nocturia d. Urine sample positive for protein

Urine sample positive for protein RATIONALE: An objective finding associated with glomerulonephritis is proteinuria. Dysuria is a symptom of urinary tract infection. Oliguria occurs in renal dysfunction. Nocturia can occur with cardiovascular disease.

The nurse is analyzing a patient's cardiac rhythm strip. Which method should the nurse use to determine rhythm regularity? a. Using ECG calipers, place one point at the peak of a P wave or R wave, then adjust the other point of the calipers to the peak of the next wave (e.g., P to P wave, R to R wave). Holding the calipers at that distance, evaluate the distance between consecutive waves. b. Place a second ECG strip that has been confirmed as having regular P waves and R waves over the patient's ECG strip and compare the waves to each other using ECG calipers. c. Count the number of small boxes between two consecutive R waves and measure each wave after that using the number of boxes that were counted originally. Once all R waves have been measured, apply the same method to P waves. Using a pair of ECG calipers, measure from the peak of P wave to the next peak of an R wave. d. Record that measurement, then repeat for the next set of consecutive P and R peaks. Continue for all peaks, recording each measurement, then evaluate measurements.

Using ECG calipers, place one point at the peak of a P wave or R wave, then adjust the other point of the calipers to the peak of the next wave (e.g., P to P wave, R to R wave). Holding the calipers at that distance, evaluate the distance between consecutive waves.