unit 4 mix questions 1
What is the appropriate infusion time for the dialysate in your 38 y.o. patient with chronic renal failure? 1. 15 minutes 2. 30 minutes 3. 1 hour 4. 2 to 3 hours
1. 15 minutes Dialysate should be infused quickly. The dialysate should be infused over 15 minutes or less when performing peritoneal dialysis. The fluid exchange takes place over a period ranging from 30 minutes to several hours.
Which intervention do you plan to include with a patient who has renal calculi? 1. Maintain bed rest 2. Increase dietary purines 3. Restrict fluids 4. Strain all urine
4. Strain all urine All urine should be strained through gauze or a urine strainer to catch stones that are passed. The stones are then analyzed for composition. Ambulation may help the movement of the stone down the urinary tract. Encourage fluid to help flush the stones out
A 26-year-old female client seeks care for a possible infection. Her symptoms include burning on urination and frequent, urgent voiding of small amounts of urine. She's placed on trimethoprim-sulfamethoxazole (Bactrim) to treat possible infection. Another medication is prescribed to decrease the pain and frequency. Which of the following is the most likely medication prescribed? A. nitrofurantoin (Macrodantin) B. ibuprofen (Motrin) C. acetaminophen with codeine D. phenazopyridine (Pyridium)
D. phenazopyridine (Pyridium) Phenazopyridine may be prescribed in conjunction with an antibiotic for painful bladder infections to promote comfort. Because of its local anesthetic action on the urinary mucosa, phenazopyridine specifically relieves bladder pain. Nitrofurantoin is a urinary antiseptic with no analgesic properties. While ibuprofen and acetaminophen with codeine are analgesics, they don't exert a direct effect on the urinary mucosa.
You have a patient that is receiving peritoneal dialysis. What should you do when you notice the return fluid is slowly draining? 1. Check for kinks in the outflow tubing. 2. Raise the drainage bag above the level of the abdomen. 3. Place the patient in a reverse Trendelenburg position. 4. Ask the patient to cough.
1. Check for kinks in the outflow tubing. Tubing problems are a common cause of outflow difficulties, check the tubing for kinks and ensure that all clamps are open. Other measures include having the patient change positions (moving side to side or sitting up), applying gentle pressure over the abdomen, or having a bowel movement.
What change indicates recovery in a patient with nephritic syndrome? 1. Disappearance of protein from the urine 2. Decrease in blood pressure to normal 3. Increase in serum lipid levels 4. Gain in body weight
1. Disappearance of protein from the urine With nephrotic syndrome, the glomerular basement membrane of the kidney becomes more porous, leading to loss of protein in the urine. As the patient recovers, less protein is found in the urine.
After the first hemodialysis treatment, your patient develops a headache, hypertension, restlessness, mental confusion, nausea, and vomiting. Which condition is indicated? 1. Disequilibrium syndrome 2. Respiratory distress 3. Hypervolemia 4. Peritonitis
1. Disequilibrium syndrome Disequilibrium occurs when excess solutes are cleared from the blood more rapidly than they can diffuse from the body's cells into the vascular system.
You have a paraplegic patient with renal calculi. Which factor contributes to the development of calculi? 1. Increased calcium loss from the bones 2. Decreased kidney function 3. Decreased calcium intake 4. High fluid intake
1. Increased calcium loss from the bones Bones lose calcium when a patient can no longer bear weight. The calcium lost from bones form calculi, a concentration of mineral salts also known as a stone, in the renal system.
A patient with diabetes mellitus and renal failure begins hemodialysis. Which diet is best on days between dialysis treatments? 1. Low-protein diet with unlimited amounts of water 2. Low-protein diet with a prescribed amount of water 3. No protein in the diet and use of a salt substitute 4. No restrictions
1. Low-protein diet with a prescribed amount of water The patient should follow a low-protein diet with a prescribed amount of water. The patient requires some protein to meet metabolic needs. Salt substitutes shouldn't be used without a doctor's order because it may contain potassium, which could make the patient hyperkalemic. Fluid and protein restrictions are needed.
Which criterion is required before a patient can be considered for continuous peritoneal dialysis? 1. The patient must be hemodynamically stable 2. The vascular access must have healed 3. The patient must be in a home setting 4. Hemodialysis must have failed
1. The patient must be hemodynamically stable Hemodynamic stability must be established before continuous peritoneal dialysis can be started.
You have a patient that might have a urinary tract infection (UTI). Which statement by the patient suggests that a UTI is likely? 1. "I pee a lot." 2. "It burns when I pee." 3. "I go hours without the urge to pee." 4. "My pee smells sweet."
2. "It burns when I pee." A common symptom of a UTI is dysuria. A patient with a UTI often reports frequent voiding of small amounts and the urgency to void. Urine that smells sweet is often associated with diabetic ketoacidosis.
You expect a patient in the oliguric phase of renal failure to have a 24 hour urine output less than: 1. 200ml 2. 400ml 3. 800ml 4. 1000ml
2. 400ml Oliguria is defined as urine output of less than 400ml/24hours.
A 30 y.o. female patient is undergoing hemodialysis with an internal arteriovenous fistula in place. What do you do to prevent complications associated with this device? 1. Insert I.V. lines above the fistula. 2. Avoid taking blood pressures in the arm with the fistula. 3. Palpate pulses above the fistula. 4. Report a bruit or thrill over the fistula to the doctor.
2. Avoid taking blood pressures in the arm with the fistula. Don't take blood pressure readings in the arm with the fistula because the compression could damage the fistula. IV lines shouldn't be inserted in the arm used for hemodialysis. Palpate pulses below the fistula. Lack of bruit or thrill should be reported to the doctor
Which of the following symptoms do you expect to see in a patient diagnosed with acute pyelonephritis? 1. Jaundice and flank pain 2. Costovertebral angle tenderness and chills 3. Burning sensation on urination 4. Polyuria and nocturia
2. Costovertebral angle tenderness and chills Costovertebral angle tenderness, flank pain, and chills are symptoms of acute pyelonephritis. Jaundice indicates gallbladder or liver obstruction. A burning sensation on urination is a sign of lower urinary tract infection.
Your patient becomes restless and tells you she has a headache and feels nauseous during hemodialysis. Which complication do you suspect? 1. Infection 2. Disequilibrium syndrome 3. Air embolus 4. Acute hemolysis
2. Disequilibrium syndrome Disequilibrium syndrome is caused by a rapid reduction in urea, sodium, and other solutes from the blood. This can lead to cerebral edema and increased intracranial pressure (ICP). Signs and symptoms include headache, nausea, restlessness, vomiting, confusion, twitching, and seizures.
A patient returns from surgery with an indwelling urinary catheter in place and empty. Six hours later, the volume is 120ml. The drainage system has no obstructions. Which intervention has priority? 1. Give a 500 ml bolus of isotonic saline 2. Evaluate the patient's circulation and vital signs 3. Flush the urinary catheter with sterile water or saline 4. Place the patient in the shock position, and notify the surgeon
2. Evaluate the patient's circulation and vital signs A total UO of 120ml is too low. Assess the patient's circulation and hemodynamic stability for signs of hypovolemia. A fluid bolus may be required, but only after further nursing assessment and a doctor's order.
Your 60 y.o. patient with pyelonephritis and possible septicemia has had five UTIs over the past two years. She is fatigued from lack of sleep, has lost weight, and urinates frequently even in the night. Her labs show: sodium, 154 mEq/L; osmolarity 340 mOsm/L; glucose, 127 mg/dl; and potassium, 3.9 mEq/L. Which nursing diagnosis is priority? 1. Fluid volume deficit related to osmotic diuresis induced by hyponatremia 2. Fluid volume deficit related to inability to conserve water 3. Altered nutrition: Less than body requirements related to hypermetabolic state 4. Altered nutrition: Less than body requirements related to catabolic effects of insulin deficiency
2. Fluid volume deficit related to inability to conserve water
What is the priority nursing diagnosis with your patient diagnosed with end-stage renal disease? 1. Activity intolerance 2. Fluid volume excess 3. Knowledge deficit 4. Pain
2. Fluid volume excess Fluid volume excess because the kidneys aren't removing fluid and wastes. The other diagnoses may apply, but they don't take priority.
Immediately post-op after a prostatectomy, which complications requires priority assessment of your patient? 1. Pneumonia 2. Hemorrhage 3. Urine retention 4. Deep vein thrombosis
2. Hemorrhage Hemorrhage is a potential complication. Urine retention isn't a problem soon after surgery because a catheter is in place. Pneumonia may occur if the patient doesn't cough and deep breathe. Thrombosis may occur later if the patient doesn't ambulate.
Your patient is complaining of muscle cramps while undergoing hemodialysis. Which intervention is effective in relieving muscle cramps? 1. Increase the rate of dialysis 2. Infuse normal saline solution 3. Administer a 5% dextrose solution 4. Encourage active ROM exercises
2. Infuse normal saline solution Treatment includes administering normal saline or hypertonic normal saline solution because muscle cramps can occur when the sodium and water are removed to quickly during dialysis. Reducing the rate of dialysis, not increasing it, may alleviate muscle cramps.
Which patient is at greatest risk for developing a urinary tract infection (UTI)? 1. A 35 y.o. woman with a fractured wrist 2. A 20 y.o. woman with asthma 3. A 50 y.o. postmenopausal woman 4. A 28 y.o. with angina
3. A 50 y.o. postmenopausal woman Women are more prone to UTI's after menopause due to reduced estrogen levels. Reduced estrogen levels lead to reduced levels of vaginal Lactobacilli bacteria, which protect against infection. Angina, asthma and fractures don't increase the risk of UTI
Polystyrene sulfonate (Kayexalate) is used in renal failure to: 1. Correct acidosis 2. Reduce serum phosphate levels 3. Exchange potassium for sodium 4. Prevent constipation from sorbitol use
3. Exchange potassium for sodium In renal failure, patients become hyperkalemic because they can't excrete potassium in the urine. Polystyrene sulfonate acts to excrete potassium by pulling potassium into the bowels and exchanging it for sodium.
Clinical manifestations of acute glomerulonephritis include which of the following? 1. Chills and flank pain 2. Oliguria and generalized edema 3. Hematuria and proteinuria 4. Dysuria and hypotension
3. Hematuria and proteinuria Hematuria and proteinuria indicate acute glomerulonephritis. These finding result from increased permeability of the glomerular membrane due to the antigen-antibody reaction. Generalized edema is seen most often in nephrosis.
Which finding leads you to suspect acute glomerulonephritis in your 32 y.o. patient? 1. Dysuria, frequency, and urgency 2. Back pain, nausea, and vomiting 3. Hypertension, oliguria, and fatigue 4. Fever, chills, and right upper quadrant pain radiating to the back
3. Hypertension, oliguria, and fatigue Mild to moderate HTN may result from sodium or water retention and inappropriate renin release from the kidneys. Oliguria and fatigue also may be seen. Other signs are proteinuria and azotemia.
A patient with diabetes has had many renal calculi over the past 20 years and now has chronic renal failure. Which substance must be reduced in this patient's diet? 1. Carbohydrates 2. Fats 3. Protein 4. Vitamin C
3. Protein Because of damage to the nephrons, the kidney can't excrete all the metabolic wastes of protein, so this patient's protein intake must be restricted. A higher intake of carbs, fats, and vitamin supplements is needed to ensure the growth and maintenance of the patient's tissues.
An 18 y.o. student is admitted with dark urine, fever, and flank pain and is diagnosed with acute glomerulonephritis. Which would most likely be in this student's health history? 1. Renal calculi 2. Renal trauma 3. Recent sore throat 4. Family history of acute glomerulonephritis
3. Recent sore throat The most common form of acute glomerulonephritis is caused by group A beta-hemolytic streptococcal infection elsewhere in the body.
A patient is experiencing which type of incontinence if she experiences leaking urine when she coughs, sneezes, or lifts heavy objects? 1. Overflow 2. Reflex 3. Stress 4. Urge
3. Stress Stress incontinence is an involuntary loss of a small amount of urine due to sudden increased intra-abdominal pressure, such as with coughing or sneezing.
Which instructions do you include in the teaching care plan for a patient with cystitis receiving phenazopyridine (Pyridium). 1. If the urine turns orange-red, call the doctor. 2. Take phenazopyridine just before urination to relieve pain. 3. Once painful urination is relieved, discontinue prescribed antibiotics. 4. After painful urination is relieved, stop taking phenazopyridine.
4. After painful urination is relieved, stop taking phenazopyridine. Pyridium is taken to relieve dysuria because is provides an analgesic and anesthetic effect on the urinary tract mucosa. The patient can stop taking it after the dysuria is relieved. The urine may temporarily turn red or orange due to the dye in the drug. The drug isn't taken before voiding, and is usually taken 3 times a day for 2 days.
Your patient has complaints of severe right-sided flank pain, nausea, vomiting and restlessness. He appears slightly pale and is diaphoretic. Vital signs are BP 140/90 mmHg, Pulse 118 beats/min., respirations 33 breaths/minute, and temperature, 98.0F. Which subjective data supports a diagnosis of renal calculi? 1. Pain radiating to the right upper quadrant 2. History of mild flu symptoms last week 3. Dark-colored coffee-ground emesis 4. Dark, scanty urine output
4. Dark, scanty urine output Patients with renal calculi commonly have blood in the urine caused by the stone's passage through the urinary tract. The urine appears dark, tests positive for blood, and is typically scant.
You're preparing for urinary catheterization of a trauma patient and you observe bleeding at the urethral meatus. Which action has priority? 1. Irrigate and clean the meatus before catheterization 2. Check the discharge for occult blood before catheterization 3. Heavily lubricate the catheter before insertion 4. Delay catheterization and notify the doctor
4. Delay catheterization and notify the doctor Bleeding at the urethral meatus is evidence that the urethra is injured. Because catheterization can cause further harm, consult with the doctor.
A patient diagnosed with sepsis from a UTI is being discharged. What do you plan to include in her discharge teaching? 1. Take cool baths 2. Avoid tampon use 3. Avoid sexual activity 4. Drink 8 to 10 eight-oz glasses of water daily
4. Drink 8 to 10 eight-oz glasses of water daily Drinking 2-3L of water daily inhibits bacterial growth in the bladder and helps flush the bacteria from the bladder. The patient should be instructed to void after sexual activity.
The most indicative test for prostate cancer is: 1. A thorough digital rectal examination 2. Magnetic resonance imaging (MRI) 3. Excretory urography 4. Prostate-specific antigen
4. Prostate-specific antigen An elevated prostate-specific antigen level indicates prostate cancer, but it can be falsely elevated if done after the prostate gland is manipulated. A digital rectal examination should be done as part of the yearly screening, and then the antigen test is done if the digital exam suggests cancer. MRI is used in staging the cancer.
A male client is scheduled for a renal clearance test. Nurse Sheldon should explain that this test is done to assess the kidneys' ability to remove a substance from the plasma in: A. 1 minute. B. 30 minutes. C. 1 hour. D. 24 hours.
A. 1 minute The renal clearance test determines the kidneys' ability to remove a substance from the plasma in 1 minute. It doesn't measure the kidneys' ability to remove a substance over a longer period.
A triple-lumen indwelling urinary catheter is inserted for continuous bladder irrigation following a transurethral resection of the prostate. In addition to balloon inflation, the nurse is aware that the functions of the three lumens include: A. Continuous inflow and outflow of irrigation solution. B. Intermittent inflow and continuous outflow of irrigation solution. C. Continuous inflow and intermittent outflow of irrigation solution. D. Intermittent flow of irrigation solution and prevention of hemorrhage
A. Continuous inflow and outflow of irrigation solution. When preparing for continuous bladder irrigation, a triple-lumen indwelling urinary catheter is inserted. The three lumens provide for balloon inflation and continuous inflow and outflow of irrigation solution.
Nurse Eve is caring for a client who had a cerebrovascular accident (CVA). Which nursing intervention promotes urinary continence? A. Encouraging intake of at least 2 L of fluid daily B. Giving the client a glass of soda before bedtime C. Taking the client to the bathroom twice per day D. Consulting with a dietitian
A. Encouraging intake of at least 2 L of fluid daily By encouraging a daily fluid intake of at least 2 L, the nurse helps fill the client's bladder, thereby promoting bladder retraining by stimulating the urge to void. The nurse shouldn't give the client soda before bedtime; soda acts as a diuretic and may make the client incontinent. The nurse should take the client to the bathroom or offer the bedpan at least every 2 hours throughout the day; twice per day is insufficient. Consultation with a dietitian won't address the problem of urinary incontinence.
Nurse Karen is caring for a client who had a cerebrovascular accident (CVA). Which nursing intervention promotes urinary continence? A. Encouraging intake of at least 2 L of fluid daily B. Giving the client a glass of soda before bedtime C. Taking the client to the bathroom twice per day D. Consulting with a dietitian
A. Encouraging intake of at least 2 L of fluid daily By encouraging a daily fluid intake of at least 2 L, the nurse helps fill the client's bladder, thereby promoting bladder retraining by stimulating the urge to void. The nurse shouldn't give the client soda before bedtime; soda acts as a diuretic and may make the client incontinent. The nurse should take the client to the bathroom or offer the bedpan at least every 2 hours throughout the day; twice per day is insufficient. Consultation with a dietitian won't address the problem of urinary incontinence.
A male client comes to the emergency department complaining of sudden onset of sharp, severe pain in the lumbar region, which radiates around the side and toward the bladder. The client also reports nausea and vomiting and appears pale, diaphoretic, and anxious. The physician tentatively diagnosed renal calculi and orders flat-plate abdominal X-rays. Renal calculi can form anywhere in the urinary tract. What is their most common formation site? A. Kidney B. Ureter C. Bladder D. Urethra
A. Kidney The most common site of renal calculi formation is the kidney. Calculi may travel down the urinary tract with or without causing damage and may lodge anywhere along the tract or may stay within the kidney. The ureter, bladder, and urethra are less common sites of renal calculi formation.
Nurse Vic is monitoring the fluid intake and output of a female client recovering from an exploratory laparotomy. Which nursing intervention would help the client avoid a urinary tract infection (UTI)? A. Maintaining a closed indwelling urinary catheter system and securing the catheter to the leg B. Limiting fluid intake to 1 L/day C. Encouraging the client to use a feminine deodorant after bathing D. Encouraging the client to douche once a day after removal of the indwelling urinary catheter
A. Maintaining a closed indwelling urinary catheter system and securing the catheter to the leg Maintaining a closed indwelling urinary catheter system helps prevent introduction of bacteria; securing the catheter to the client's leg also decreases the risk of infection by helping to prevent urethral trauma. To flush bacteria from the urinary tract, the nurse should encourage the client to drink at least 10 glasses of fluid daily, if possible. Douching and feminine deodorants may irritate the urinary tract and should be discouraged.
A 55-year old client with benign prostatic hyperplasia doesn't respond to medical treatment and is admitted to the facility for prostate gland removal. Before providing preoperative and postoperative instructions to the client, Nurse Gerry asks the surgeon which prostatectomy procedure will be done. What is the most widely used procedure for prostate gland removal? A. Transurethral resection of the prostate (TURP) B. Suprapubic prostatectomy C. Retropubic prostatectomy D. Transurethral laser incision of the prostate
A. Transurethral resection of the prostate (TURP) TURP is the most widely used procedure for prostate gland removal. Because it requires no incision, TURP is especially suitable for men with relatively minor prostatic enlargements and for those who are poor surgical risks. Suprapubic prostatectomy, retropubic prostatectomy, and transurethral laser incision of the prostate are less common procedures; they all require an incision.
A male client develops acute renal failure (ARF) after receiving I.V. therapy with a nephrotoxic antibiotic. Because the client's 24-hour urine output totals 240 ml, Nurse Billy suspects that the client is at risk for: A. cardiac arrhythmia. B. paresthesia. C. dehydration. D. pruritus.
A. cardiac arrhythmia. As urine output decreases, the serum potassium level rises; if it rises sufficiently, hyperkalemia may occur, possibly triggering a cardiac arrhythmia. Hyperkalemia doesn't cause paresthesia (sensations of numbness and tingling). Dehydration doesn't occur during this oliguric phase of ARF, although typically it does arise during the diuretic phase. In a client with ARF, pruritus results from increased phosphates and isn't associated with hyperkalemia.
A male client is admitted for treatment of glomerulonephritis. On initial assessment, Nurse Miley detects one of the classic signs of acute glomerulonephritis of sudden onset. Such signs include: A. generalized edema, especially of the face and periorbital area. B. green-tinged urine. C. moderate to severe hypotension. D. polyuria.
A. generalized edema, especially of the face and periorbital area. Generalized edema, especially of the face and periorbital area, is a classic sign of acute glomerulonephritis of sudden onset. Other classic signs and symptoms of this disorder include hematuria (not green-tinged urine), proteinuria, fever, chills, weakness, pallor, anorexia, nausea, and vomiting. The client also may have moderate to severe hypertension (not hypotension), oliguria or anuria (not polyuria), headache, reduced visual acuity, and abdominal or flank pain.
A female client is admitted for treatment of chronic renal failure (CRF). Nurse Julian knows that this disorder increases the client's risk of: A. water and sodium retention secondary to a severe decrease in the glomerular filtration rate. B. a decreased serum phosphate level secondary to kidney failure. C. an increased serum calcium level secondary to kidney failure. D. metabolic alkalosis secondary to retention of hydrogen ions.
A. water and sodium retention secondary to a severe decrease in the glomerular filtration rate. A client with CRF is at risk for fluid imbalance — dehydration if the kidneys fail to concentrate urine, or fluid retention if the kidneys fail to produce urine. Electrolyte imbalances associated with this disorder result from the kidneys' inability to excrete phosphorus; such imbalances may lead to hyperphosphatemia with reciprocal hypocalcemia. CRF may cause metabolic acidosis, not metabolic alkalosis, secondary to inability of the kidneys to excrete hydrogen ions.
A female client with a urinary tract infection is prescribed co-trimoxazole (trimethoprim-sulfamethoxazole). Nurse Dolly should provide which medication instruction? A. "Take the medication with food." B. "Drink at least eight 8-oz glasses of fluid daily." C. "Avoid taking antacids during co-trimoxazole therapy." D. "Don't be afraid to go out in the sun."
B. "Drink at least eight 8-oz glasses of fluid daily." When receiving a sulfonamide such as co-trimoxazole, the client should drink at least eight 8-oz glasses of fluid daily to maintain a urine output of at least 1,500 ml/day. Otherwise, inadequate urine output may lead to crystalluria or tubular deposits. For maximum absorption, the client should take this drug at least 1 hour before or 2 hours after meals. No evidence indicates that antacids interfere with the effects of sulfonamides. To prevent a photosensitivity reaction, the client should avoid direct sunlight during co-trimoxazole therapy.
Dr. Grey prescribes norfloxacin (Noroxin), 400 mg P.O. twice daily, for a client with a urinary tract infection (UTI). The client asks the nurse how long to continue taking the drug. For an uncomplicated UTI, the usual duration of norfloxacin therapy is: A. 3 to 5 days. B. 7 to 10 days. C. 12 to 14 days. D. 10 to 21 days.
B. 7 to 10 days. For an uncomplicated UTI, norfloxacin therapy usually lasts 7 to 10 days. Taking the drug for less than 7 days wouldn't eradicate such an infection. Taking it for more than 10 days isn't necessary. Only a client with a complicated UTI must take norfloxacin for 10 to 21 days.
When examining a female client's genitourinary system, Nurse Sandy assesses for tenderness at the costovertebral angle by placing the left hand over this area and striking it with the right fist. Normally, this percussion technique produces which sound? A. A flat sound B. A dull sound C. Hyperresonance D. Tympany
B. A dull sound Percussion over the costovertebral angle normally produces a dull, thudding sound, which is soft to moderately loud with a moderate pitch and duration. This sound occurs over less dense, mostly fluid-filled matter, such as the kidneys, liver, and spleen. In contrast, a flat sound occurs over highly dense matter such as muscle; hyperresonance occurs over the air-filled, overinflated lungs of a client with pulmonary emphysema or the lungs of a child (because of a thin chest wall); and tympany occurs over enclosed structures containing air, such as the stomach and bowel.
Nurse Pippy is reviewing a client's fluid intake and output record. Fluid intake and urine output should relate in which way? A. Fluid intake should be double the urine output. B. Fluid intake should be approximately equal to the urine output. C. Fluid intake should be half the urine output. D. Fluid intake should be inversely proportional to the urine output.
B. Fluid intake should be approximately equal to the urine output. Normally, fluid intake is approximately equal to the urine output. Any other relationship signals an abnormality. For example, fluid intake that is double the urine output indicates fluid retention; fluid intake that is half the urine output indicates dehydration. Normally, fluid intake isn't inversely proportional to the urine output.
After having transurethral resection of the prostate (TURP), a Mr. Lim returns to the unit with a three-way indwelling urinary catheter and continuous closed bladder irrigation. Which finding suggests that the client's catheter is occluded? A. The urine in the drainage bag appears red to pink. B. The client reports bladder spasms and the urge to void. C. The normal saline irrigant is infusing at a rate of 50 drops/minute. D. About 1,000 ml of irrigant have been instilled; 1,200 ml of drainage have been returned.
B. The client reports bladder spasms and the urge to void. Reports of bladder spasms and the urge to void suggest that a blood clot may be occluding the catheter. After TURP, urine normally appears red to pink, and normal saline irrigant usually is infused at a rate of 40 to 60 drops/minute or according to facility protocol. The amount of retained fluid (1,200 ml) should correspond to the amount of instilled fluid, plus the client's urine output (1,000 ml + 200 ml), which reflects catheter patency.
A male client with bladder cancer has had the bladder removed and an ileal conduit created for urine diversion. While changing this client's pouch, the nurse observes that the area around the stoma is red, weeping, and painful. What should Nurse Kaye conclude? A. The skin wasn't lubricated before the pouch was applied. B. The pouch faceplate doesn't fit the stoma. C. A skin barrier was applied properly. D. Stoma dilation wasn't performed.
B. The pouch faceplate doesn't fit the stoma. If the pouch faceplate doesn't fit the stoma properly, the skin around the stoma will be exposed to continuous urine flow from the stoma, causing excoriation and red, weeping, and painful skin. A lubricant shouldn't be used because it would prevent the pouch from adhering to the skin. When properly applied, a skin barrier prevents skin excoriation. Stoma dilation isn't performed with an ileal conduit, although it may be done with a colostomy if ordered.
The nurse is aware that the following findings would be further evidence of a urethral injury in a male client during rectal examination? A. A low-riding prostate B. The presence of a boggy mass C. Absent sphincter tone D. A positive Hemoccult
B. The presence of a boggy mass When the urethra is ruptured, a hematoma or collection of blood separates the two sections of urethra. This may feel like a boggy mass on rectal examination. Because of the rupture and hematoma, the prostate becomes high riding. A palpable prostate gland usually indicates a non-urethral injury. Absent sphincter tone would refer to a spinal cord injury. The presence of blood would probably correlate with GI bleeding or a colon injury.
Nurse Gil is aware that the following statements describing urinary incontinence in the elderly is true? A. Urinary incontinence is a normal part of aging. B. Urinary incontinence isn't a disease. C. Urinary incontinence in the elderly can't be treated. D. Urinary incontinence is a disease.
B. Urinary incontinence isn't a disease. Urinary incontinence isn't a normal part of aging nor is it a disease. It may be caused by confusion, dehydration, fecal impaction, restricted mobility, or other causes. Certain medications, including diuretics, hypnotics, sedatives, anticholinergics, and antihypertensives, may trigger urinary incontinence. Most clients with urinary incontinence can be treated; some can be cured.
Nurse Pete is reviewing the report of a client's routine urinalysis. Which value should the nurse consider abnormal? A. Specific gravity of 1.03 B. Urine pH of 3.0 C. Absence of protein D. Absence of glucose
B. Urine pH of 3.0 Normal urine pH is 4.5 to 8; therefore, a urine pH of 3.0 is abnormal. Urine specific gravity normally ranges from 1.002 to 1.035, making this client's value normal. Normally, urine contains no protein, glucose, ketones, bilirubin, bacteria, casts, or crystals. Red blood cells should measure 0 to 3 per high-power field; white blood cells, 0 to 4 per high-power field. Urine should be clear, its color ranging from pale yellow to deep amber.
Nurse Mary is inserting a urinary catheter into a client who is extremely anxious about the procedure. The nurse can facilitate the insertion by asking the client to: A. initiate a stream of urine. B. breathe deeply. C. turn to the side. D. hold the labia or shaft of penis.
B. breathe deeply. When inserting a urinary catheter, facilitate insertion by asking the client to breathe deeply. Doing this will relax the urinary sphincter. Initiating a stream of urine isn't recommended during catheter insertion. Turning to the side or holding the labia or penis won't ease insertion, and doing so may contaminate the sterile field.
A female client with an indwelling urinary catheter is suspected of having a urinary tract infection. Nurse Angel should collect a urine specimen for culture and sensitivity by: A. disconnecting the tubing from the urinary catheter and letting the urine flow into a sterile container. B. wiping the self-sealing aspiration port with antiseptic solution and aspirating urine with a sterile needle. C. draining urine from the drainage bag into a sterile container. D. clamping the tubing for 60 minutes and inserting a sterile needle into the tubing above the clamp to aspirate urine.
B. wiping the self-sealing aspiration port with antiseptic solution and aspirating urine with a sterile needle. Most catheters have a self-sealing port for obtaining a urine specimen. Antiseptic solution is used to reduce the risk of introducing microorganisms into the catheter. Tubing shouldn't be disconnected from the urinary catheter. Any break in the closed urine drainage system may allow the entry of microorganisms. Urine in urine drainage bags may not be fresh and may contain bacteria, giving false test results. When there is no urine in the tubing, the catheter may be clamped for no more than 30 minutes to allow urine to collect.
After undergoing transurethral resection of the prostate to treat benign prostatic hyperplasia, a male client returns to the room with continuous bladder irrigation. On the first day after surgery, the client reports bladder pain. What should Nurse Anthony do first? A. Increase the I.V. flow rate. B. Notify the physician immediately. C. Assess the irrigation catheter for patency and drainage. D. Administer meperidine (Demerol), 50 mg I.M., as prescribed.
C. Assess the irrigation catheter for patency and drainage. Although postoperative pain is expected, the nurse should make sure that other factors, such as an obstructed irrigation catheter, aren't the cause of the pain. After assessing catheter patency, the nurse should administer an analgesic, such as meperidine, as prescribed. Increasing the I.V. flow rate may worsen the pain. Notifying the physician isn't necessary unless the pain is severe or unrelieved by the prescribed medication.
A male client with acute pyelonephritis receives a prescription for co-trimoxazole (Septra) P.O. twice daily for 10 days. Which finding best demonstrates that the client has followed the prescribed regimen? A. Urine output increases to 2,000 ml/day. B. Flank and abdominal discomfort decrease. C. Bacteria are absent on urine culture. D. The red blood cell (RBC) count is normal.
C. Bacteria are absent on urine culture. Co-trimoxazole is a sulfonamide antibiotic used to treat urinary tract infections. Therefore, absence of bacteria on urine culture indicates that the drug has achieved its desired effect. Although flank pain may decrease as the infection resolves, this isn't a reliable indicator of the drug's effectiveness. Co-trimoxazole doesn't affect urine output or the RBC count.
After trying to conceive for a year, a couple consults an infertility specialist. When obtaining a history from the husband, Nurse Jessica inquires about childhood infectious diseases. Which childhood infectious disease most significantly affects male fertility? A. Chickenpox B. Measles C. Mumps D. Scarlet fever
C. Mumps Mumps is the most significant childhood infectious disease affecting male fertility. Chickenpox, measles, and scarlet fever don't affect male fertility.
The nurse is aware that the following laboratory values supports a diagnosis of pyelonephritis? A. Myoglobinuria B. Ketonuria C. Pyuria D. Low white blood cell (WBC) count
C. Pyuria Pyelonephritis is diagnosed by the presence of leukocytosis, hematuria, pyuria, and bacteriuria. The client exhibits fever, chills, and flank pain. Because there is often a septic picture, the WBC count is more likely to be high rather than low, as indicated in option D. Ketonuria indicates a diabetic state.
Nurse Harry is aware that the following is an appropriate nursing diagnosis for a client with renal calculi? A. Ineffective tissue perfusion B. Functional urinary incontinence C. Risk for infection D. Decreased cardiac output
C. Risk for infection Infection can occur with renal calculi from urine stasis caused by obstruction. Options A and D aren't appropriate for this diagnosis, and retention of urine usually occurs, rather than incontinence.
A male client in the short-procedure unit is recovering from renal angiography in which a femoral puncture site was useD. When providing postprocedure care, the nurse should: A. keep the client's knee on the affected side bent for 6 hours. B. apply pressure to the puncture site for 30 minutes. C. check the client's pedal pulses frequently. D. remove the dressing on the puncture site after vital signs stabilize.
C. check the client's pedal pulses frequently. After renal angiography involving a femoral puncture site, the nurse should check the client's pedal pulses frequently to detect reduced circulation to the feet caused by vascular injury. The nurse also should monitor vital signs for evidence of internal hemorrhage and should observe the puncture site frequently for fresh bleeding. The client should be kept on bed rest for several hours so the puncture site can seal completely. Keeping the client's knee bent is unnecessary. By the time the client returns to the short-procedure unit, manual pressure over the puncture site is no longer needed because a pressure dressing is in place. The nurse shouldn't remove this dressing for several hours — and only if instructed to do so.
The Nurse is providing postprocedure care for a client who underwent percutaneous lithotripsy. In this procedure, an ultrasonic probe inserted through a nephrostomy tube into the renal pelvis generates ultra-high-frequency sound waves to shatter renal calculi. The nurse should instruct the client to: A. limit oral fluid intake for 1 to 2 weeks. B. report the presence of fine, sand-like particles through the nephrostomy tube. C. notify the physician about cloudy or foul-smelling urine. D. report bright pink urine within 24 hours after the procedure.
C. notify the physician about cloudy or foul-smelling urine. The client should report the presence of foul-smelling or cloudy urine. Unless contraindicated, the client should be instructed to drink large quantities of fluid each day to flush the kidneys. Sand-like debris is normal due to residual stone products. Hematuria is common after lithotripsy.
A client is frustrated and embarrassed by urinary incontinence. Which of the following measures should Nurse Ginny include in a bladder retraining program? A. Establishing a predetermined fluid intake pattern for the client B. Encouraging the client to increase the time between voidings C. Restricting fluid intake to reduce the need to void D. Assessing present elimination patterns
D. Assessing present elimination patterns The guidelines for initiating bladder retraining include assessing the client's intake patterns, voiding patterns, and reasons for each accidental voiding. Lowering the client's fluid intake won't reduce or prevent incontinence. The client should actually be encouraged to drink 1.5 to 2 L of water per day. A voiding schedule should be established after assessment.
A male client with chronic renal failure has a serum potassium level of 6.8 mEq/L. What should nurse Olivia assess first? A. Blood pressure B. Respirations C. Temperature D. Pulse
D. Pulse An elevated serum potassium level may lead to a life-threatening cardiac arrhythmia, which the nurse can detect immediately by palpating the pulse. The client's blood pressure may change, but only as a result of the arrhythmia. Therefore, the nurse should assess blood pressure later. The nurse also can delay assessing respirations and temperature because these aren't affected by the serum potassium level.
When performing a scrotal examination, Nurse Payne finds a nodule. What should the nurse do next? A. Notify the physician. B. Change the client's position and repeat the examination. C. Perform a rectal examination. D. Transilluminate the scrotum.
D. Transilluminate the scrotum. A nurse who discovers a nodule, swelling, or other abnormal finding during a scrotal examination should transilluminate the scrotum by darkening the room and shining a flashlight through the scrotum behind the mass. A scrotum filled with serous fluid transilluminates as a red glow; a more solid lesion, such as a hematoma or mass, doesn't transilluminate and may appear as a dark shadow. Although the nurse should notify the physician of the abnormal finding, performing transillumination first provides additional information. The nurse can't uncover more information about a scrotal mass by changing the client's position and repeating the examination or by performing a rectal examination.
A female adult client admitted with a gunshot wound to the abdomen is transferred to the intensive care unit after an exploratory laparotomy. Which assessment finding suggests that the client is experiencing acute renal failure (ARF)? A. Blood urea nitrogen (BUN) level of 22 mg/dl B. Serum creatinine level of 1.2 mg/dl C. Serum creatinine level of 1.2 mg/dl D. Urine output of 400 ml/24 hours
D. Urine output of 400 ml/24 hours ARF, characterized by abrupt loss of kidney function, commonly causes oliguria, which is demonstrated by a urine output of 400 ml/24 hours. A serum creatinine level of 1.2 mg/dl isn't diagnostic of ARF. A BUN level of 22 mg/dl or a temperature of 100.2° F (37.8° C) wouldn't result from this disorder.
The client underwent a transurethral resection of the prostate gland 24 hours ago and is on continuous bladder irrigation. Nurse Yonny is aware that the following nursing interventions is appropriate? A. Tell the client to try to urinate around the catheter to remove blood clots. B. Restrict fluids to prevent the client's bladder from becoming distended. C. Prepare to remove the catheter. D. Use aseptic technique when irrigating the catheter.
D. Use aseptic technique when irrigating the catheter. If the catheter is blocked by blood clots, it may be irrigated according to physician's orders or facility protocol. The nurse should use sterile technique to reduce the risk of infection. Urinating around the catheter can cause painful bladder spasms. Encourage the client to drink fluids to dilute the urine and maintain urine output. The catheter remains in place for 2 to 4 days after surgery and is only removed with a physician's order.
Because of difficulties with hemodialysis, peritoneal dialysis is initiated to treat a female client's uremia. Which finding signals a significant problem during this procedure? A. Potassium level of 3.5 mEq/L B. Hematocrit (HCT) of 35% C. Blood glucose level of 200 mg/dl D. White blood cell (WBC) count of 20,000/mm3
D. White blood cell (WBC) count of 20,000/mm3 An increased WBC count indicates infection, probably resulting from peritonitis, which may have been caused by insertion of the peritoneal catheter into the peritoneal cavity. Peritonitis can cause the peritoneal membrane to lose its ability to filter solutes; therefore, peritoneal dialysis would no longer be a treatment option for this client. Hyperglycemia occurs during peritoneal dialysis because of the high glucose content of the dialysate; it's readily treatable with sliding-scale insulin. A potassium level of 3.5 mEq/L can be treated by adding potassium to the dialysate solution. An HCT of 35% is lower than normal. However, in this client, the value isn't abnormally low because of the daily blood samplings. A lower HCT is common in clients with chronic renal failure because of the lack of erythropoietin.
