ATI Renal and Uro DQ

A nurse is caring for a client who is receiving intermittent peritoneal dialysis. The nurse observes that the peritoneal fluid is not adequately draining. Which of the following actions should the nurse take? A. Turn the client from side to side B. Elevate the height of the dialysate bag C. Lower the head of the client's bed D. Advance the catheter approximately 2.5 cm (1in) further

A. Turn the client from side to side The nurse should assist the client in turning from side to side to facilitate the removal of peritoneal drainage. This action helps ensure there are no kinks in the tubing or an air lock in the peritoneal catheter. Nurses should raise the height of the dialysate bag to increase the rate of inflow; however, this action will not promote outflow of peritoneal fluid. Nurse should elevate head of the bed to promote outflow of the peritoneal fluid. Nurse should not push the peritoneal catheter further into the peritoneal cavity because this action introduces bacteria into the peritoneal cavity and increases the client's risk for peritonitis.

A nurse is collecting data from a client who has urolithiasis and reports pain in his thigh. The nurse should identify that this finding indicates the stone is in which of the following structures? A. Ureter B. Bladder C. Renal pelvis D. Renal tubules

A. Ureter When stones are in the ureters, pain radiates to the genitalia and to the thighs. Stones in the bladder produce manifestations of irritation that resembles a UTI. They can also cause pain in the vulva and scrotal areas. The renal pelvis is part of the kidney. Stones in the kidneys cause pain in the CVA regions. The renal tubules are within the nephron, which is part of the kidney. Stones in the kidneys cause flank pain.

A nurse is collecting data from a client who is PostOperative following a transurethral resection of the prostate (TURP), After the nurse discontinues the client's Urinary Catheter, Which of the following findings should the nurse report to the provider? A.Decrease Urine output B.Report of burning upon urination C.stress incontinence D.pink-tinged urine

A.Decrease Urine output A decrease in urine output after a TURP indicates an obstruction to urine flow by a clot or residual prostatic tissue and Should be reported to the provider

A nurse is caring for a client who has chronic glomerulonephritis with oliguria. For which of the following electrolyte imbalances should the nurse monitor? A. Hypercalcemia B. Hyperkalemia C. Hypomagnesemia D. Hypophosphatemia

B. Hyperkalemia Oliguria resulting from chronic glomerulonephritis causes potassium retention, leading to levels above the expected reference range of 3.5 to 5 mEq to 5 mEq/L. Other electrolyte imbalances common with this disorder affect sodium and phosphorus levels. Chronic glomerulonephritis eventually leads to end-stage kidney disease.

A nurse is caring for a client who is receiving peritoneal dialysis. The nurse monitors the client for which of the following adverse effects? A) Diarrhea B) Increased serum albumin C) Hypoglycemia D) Respiratory distress

D) Respiratory distress Respiratory distress can occur during peritoneal dialysis due to fluid overload

A nurse is providing dietary teaching to a client who has chronic renal failure. Which food choice by the client indicates an understanding of the teaching? A. Canned Soup B. Grilled Fish C. Pastrami D. Peanut Butter

Grilled Fish Protein choices, such as fresh fish or poultry, can minimize the risk of worsening chronic renal failure.Additional recommendations:Foods that are high in sodium (canned soup, pastrami, peanut butter) should be avoided by clients who have chronic renal failure.

A nurse is collecting data on a client who is 4 hours postoperative following a transurethral resection of the prostate and has an indwelling urinary catheter in place. Which of the following findings should the nurse expect? a) Blood-tinged urine in the drainage bad b) Catheter tubing coiled at the client's side c) Client report of severe bladder spasms d) Urinary output of 20 mL/hr

a) Blood-tinged urine in the drainage bad The nurse should identify that blood-tinged urine in the drainage bag is an expected finding for the first few days following surgery.

A nurse is reinforcing teaching with a client who has a history of urinary tract infections (UTIs). Which of the following statements should indicate to the nurse the need for additional instructions? a. "I will use a vaginal douche daily." b. "I will empty my bladder every 2 to 4 hours." c. "I will drink 2 liters of fluids per day." d. "I will wear cotton underwear."

a. "I will use a vaginal douche daily." The client should avoid vaginal douches, bubble baths, and any substances that can increase the risk for UTIs. The client should use mild soap and water to wash the perineal area.

A nurse is collecting data from a client who is receiving continuous ambulatory peritoneal dialysis. Which of the following findings should the nurse report to the provider? a. Cloudy, yellow drainage b. WBC 6,000 c. Potassium 4.0 mEq/L d. Report of abdominal fullness

A. Cloudy, yellow drainage Cloudy, yellow drainage is an early manifestation of peritonitis and the nurse should report this finding to the provider. Other manifestations include fever and abdominal tenderness. if potassium is low like 3 - report too

A nurse is caring for a client who has manifestations of acute tubular necrosis (ATN) following a kidney transplantation. Which of the following interventions should the nurse anticipate for this client? (Select All That Apply) a. Hemodialysis b. Biopsy c. Immunosuppression d. Balloon angioplasty e. Surgical repair

A. Hemodialysis B. Biopsy C. Immunosuppression Clients who develop ATN after transplantation surgery might need dialysis until they have an adequate urine output and their BUN and creatinine levels stabilize. Because the development of ATN after transplantation surgery mimics the symptoms of rejection of the transplanted kidney, clients have to undergo a biopsy to determine the correct diagnosis. Immunosuppressive medication therapy is essential after kidney transplantation to protect the new kidney.

A nurse is preparing an in-service program about the stages of acute kidney injury (AKI). Which of the following pieces of information should the nurse include about prerenal azotemia? (a) Prerenal azotemia begins prior to the onset of symptoms. (b) Interference with renal perfusion causes prerenal azotemia. (c) Prerenal azotemia is irreversible, even in the early stages. (d) Infections and tumors cause prerenal azotemia.

(b) Interference with renal perfusion causes prerenal azotemia. Prerenal azotemia results from interference with renal perfusion (e.g. heart failure or hypovolemic shock).

A nurse is teaching a client who has chronic kidney disease (CKD). Which of the following instructions should the nurse include? A. Limit fluid intake B. Limit caloric intake C. Eat a diet high in phosphorus D. Eat a diet high in protein

A. Limit Fluid intake A client who has CKD should limit fluid intake to prevent hypervolemia or excessive fluid overload. A client who has CKD should increase caloric intake so that the body can use protein for protein synthesis instead of energy consuption. Using protein for energy can lead to a negative nitrogen balance and malnutrition. A client who has CKD should limit phosphorus intake because the kidneys are unable to excrete it. A client who has CKD should not eat excessive protein to prevent the build-up of protein waste and uremia.

A nurse is contributing to the plan of care for a client who had a stroke. The client has hemiplegia and occasional urinary incontinence. Which of the following interventions should the nurse recommend? A. Offer the client a bedpan every 2 hours B. Limit the clients daily fluid intake until he is no longer incontinent C. Request a prescription for an indwelling catheter from the clients provider D. Ambulate the client to the bathroom every 30 minutes

A. Offer the client a bedpan every 2 hours Following a stroke the client might have bladder incontinence due to confusion, impaired sensation, in response to bladder fullness, and decreased sphincter control. The nurse should encourage the client to void every 2 hours while awake to promote bladder control. By offering the bedpan the nurse promotes client safety.

A nurse is teaching a client with chronic kidney disease about predialysis dietary recommendations. The nurse should recommend restricting the intake of which nutrients? A. Protein B. Carbohydrates C. Calcium D. Monounsaturated fats

A. Protein Dietary restrictions for clients who have chronic kidney disease vary based on the degree of kidney function; however, most clients need protein limitations. Predialysis protein restriction can help preserve some kidney function.

A nurse is collecting a.data from a client who is postoperative following extracorporeal shockwave lithotripsy (ESWL). The nurse should identify that which of the following findings is the priority? a. Report of Palpitations b. bruising on the flank area c. stone fragments in the urine d. pink-tinged urine

A. Report of Palpitations The nurse should apply the ABC priority-setting framework. This framework emphasizes the basic core of human functioning - having an open airway, being able to breathe in adequate amounts of oxygen, and circulating oxygen to the body's organs via the blood. An alteration in any of these can indicate a threat to life, and is the nurse's priority concern. When applying the ABC priority-setting framework, airway is always the highest priority because the airway must be clear and open for oxygen exchange to occur. Breathing is the second-highest priority in the ABC priority-setting framework because adequate ventilatory effort is essential in order for oxygen exchange to occur. Circulation is the third-highest priority in the ABC priority-setting framework because delivery of oxygen to critical organs only occurs if the heart and blood vessels are capable of efficiently carrying oxygen to them. ESWL is the application of sound, laser, or dry shock wave energies to break a kidney stone into small pieces. The shock waves are initiated during the R wave of the ECG to prevent dysrhythmias. When using the airway, breathing, circulation approach to client care, the nurse should determine report of palpitations is a manifestation of dysrhythmias and is the priority finding

A nurse is reinforcing dietary teaching with a client who has late stage chronic kidney disease (CKD). Which of the following nutrients should the nurse instruct the client to increase in her diet A. Calcium B. Phosphorus C. Potassium D. Sodium

Answer a. Calcium A client who has CKD can develop hypocalcemia due to the reduced production of active vitamin D, which is needed for calcium absorption. The client should supplement her diet with dietary calcium. Phosphorous A client who has CKD can develop hyperphosphatemia because excretion of phosphorous by the kidneys is reduced. Potassium A client who has CKD can develop hyperkalemia because excretion of potassium by the kidneys is reduced. Sodium A client who has CKD can develop hypernatremia because excretion of sodium by the kidneys is reduced.

A nurse is reinforcing teaching with a client who has gout and urolithiasis. The client asks how to prevent future uric acid stones. Which of the following suggestions should the nurse provide? (SATA) A. Take allopurinol as prescribed B. Exercise several times a week C. Limit intake of foods high in purine D. Decrease daily fluid intake E. Avoid lemonade

Answer: A, B, C A. Take allopurinol as prescribed B. Exercise several times a week C. Limit intake of foods high in purine The nurse should inform the client that allopurinol is an antigout medication that reduces the level of uric acid, which helps prevent uric acid stone formation. Immobility is a risk factor for urinary stasis and stone formation; therefore, the client should maintain a healthy lifestyle, including regular exercise, to help prevent stone formation. Purine increases the risk of uric acid stone formation. The nurse should identify that organ meats, poultry, fish, red wine, and gravies are high in purine.

A nurse is reinforcing teaching about urinary tract infections (UTIs) with a client. Which of the following manifestations should the nurse include? A. Weight gain B. Back pain C. Vaginal discharge D. Muscle cramps

B. Back pain Back pain and flank pain are manifestations of a UTI. Other manifestations include frequency, urgency, and cloudy, foul smelling urine

A nurse is caring for a client who is in the oliguric-anuric stage of acute kidney injury. The client reports diarrhea, a dull headache, palpitations, and muscle tingling and weakness, Which of the following actions should the nurse take first? A. Administer an analgesic to the client B. Check the client's electrolyte values C. Measure the client's weight D. Restrict the client's protein

B. Check the client's electrolyte values The nurse should apply the urgent versus non-urgent priority-setting framework when caring for the client. Using this framework, the nurse should consider urgent needs to be the priority because they pose a greater threat to the client. The nurse might also need to use Maslow's hierarchy of needs, the ABC priority-setting framework, and/or nursing knowledge to identify which finding is the most urgent. The nurse should check the client's most recent potassium value because these findings are manifestations of hyperkalemia, which can lead to cardiac dysrhythmias.

A nurse is conducting dietary teaching with a client who has a history of renal calculi. Which instruction should the nurse include in the teaching? A. Consume foods containing Vitamin C B. Drink 3.8 L (4qt) of water throughout the day C. Suggest almonds as a snack D. Limit sodium intake to 3 g per day

B. Drink 3.8 L (4 qt) of water throughout the day. The nurse should instruct the client to drink 3.8 L of water per day to keep urine diluted and decrease the risk of kidney stone formation. Avoid large amounts of Vitamin C which can increase risk of kidney stone formation. Avoid high-oxalate foods like almonds or other types of nuts because they increase risk of kidney stone formation. Limit soidum to 2 g per day. High sodium increases risk for kidney stone formation.

A nurse is reviewing the laboratory report for a client who has chronic kidney disease (CKD). The nurse finds the following laboratory test results: potassium 6.8 mEq/L, calcium 7.4 mg/dL, hemoglobin 10.2 g/dL, and phosphate 4.8 mg/dL. Which of the following findings is the priority for the nurse to report to the provider? A. Hypocalcemia B. Hyperkalemia C. Anemia D. Hypoalbuminemia

B. Hyperkalemia Hyperkalemia [The nurse should apply the urgent versus non-urgent priority-setting framework when caring for this client. Using this framework, the nurse should consider urgent needs the priority need because they pose more of a threat to the client. The nurse may also need to use Maslow's hierarchy of needs, the ABC priority-setting framework, or nursing knowledge to identify which finding is the most urgent. Therefore, hyperkalemia, which can cause life-threatening cardiac dysrhythmias, is the priority for the nurse to report to the provider.

A female client who has a recurrent cystitis asks the nurse about preventing future episodes. For which of the following statements should the nurse provide teaching reinforcement? A. I drink at least 2 L of fluid per day B. I prefer tub baths to showering C. I uriniate after sexual relations D. I wipe from front to back after urination

B. I prefer tub baths to showering Cystitis is an inflammation of the bladder lining that commonly occurs with a UTI. Women who are at risk for UTIs should avoid tub baths because they can increase risk of infection

A nurse is reinforcing teaching with a female client who has pyelonephritis about the disorder. Which of the following pieces of information should the nurse include to help the client prevent a recurrence? A. Douche after vaginal intercourse B. Wipe from front to back after defecation C. Avoid foods that are high in phosphate D. Add yogurt to your diet regularly

B. Wipe from front to back after defecation Pyelonephritis is a bacterial infection of the kidney and renal pelvis. The nurse should instruct the client about the importance of wiping from front to back following fecal elimination to prevent introducing bacteria into the urinary tract, which can ultimately cause pyelonephritis.

A nurse is providing teaching to a young adult client who has a history of calcium oxalate renal calculi. which of the following instructions should the nurse include? A, drink fruit punch or juice with every meal B. consume 1,000 mg of dietary calcium daily C. take 1 g of vitamin C daily D. increase your daily bran intake

B. consume 1,000 mg of dietary calcium daily Clients who are prone to the development of calcium oxalate stones should consume the recommended daily allowance for calcium for their age. The RDA for calcium for adults ages 19-50 is 1000 mg/day. Calcium should be obtained from dietary sources rather than supplements that can promote the development of renal calculi.

A nurse is preparing a client who is scheduled for an intravenous pyelogram (IVP) Which of the following findings should the nurse report to the provider? A) Allergy to egg products B) Vomiting and diarrhea for the last 6 hours C) Serum potassium of 3.6 mEq/L D) Serum creatinine of 1.2 mg/dL

B.Vomiting and diarrhea for the last 6 hours The nurse should identify that vomiting and diarrhea for 6 hours deplete the client's fluid volume, which results in dehydration that can cause renal failure following a procedure that uses contrast dye. Therefore, the nurse should notify the provider.

A nurse is caring for a client who has a continuous bladder irrigation following a transurethral resection of the prostate (TURP). Which of the following actions should the nurse take? a. Irrigate the catheter with a sterile water b. Clamp the drainage catheter during ambulation c. Report viscous drainage with clots to the provider d. Remove the catheter if the client feels a strong urge to urinate

C. Report viscous drainage with clots to the provider The nurse should report urine output that is bright red with clots or urine that resembles ketchup to the provider, as this is indication of hemorrhage.

A nurse is caring for a client who has just returned from the surgical suite following a right nephrectomy. Which of the following indicates that the client is meeting a successful short-term goal following this procedure? A. The client requests pain medication upon arrival from surgery B. A chest x-ray shows consolidation in the right lower lobe C. Urinary output is 35 to 50 mL/hr consistently D. The client has slight abdominal distention

C. Urinary output is 35 to 50 mL/hr consistently Following a nephrectomy, the client should have a urine output of at least 30 mL/hr consistently. Less than that indicates inadequate blood flow to the remaining kidney

A nurse is teaching a client who is preoperative for a renal biopsy. Which of the following statements should the nurse make? A. You will be NPO for 8 hrs following the procedure B. An allergy to shellfish is a contraindication to this procedure C. You will need to be on bed rest following the procedure D. A creatinine clearance is needed prior to the procedure.

C. You will need to be on bed rest following the procedure A renal biopsy involves a tissue biopsy through needle insertion into the lower lobe of the kidney./ The client should maintain bed rest in a supine position with a back roll for support for 2 to 24 hours following the procedure to reduce the risk of bleeding. The nurse can elevate the head of the bed. NPO for 4 to 8 hours prior to the procedure; however food and fluids can resume following the procedure. An allergy to shellfish is not a contraindication to the procedure because contrast media is not used. Because of the risk for post-procedural bleeding. Preliminary lab tests include coagulation studies such as platelet count and prothrombin time. Tests for anemia are also done to evaluate whether a pre-procedural blood transfusion is needed. Creatinine clearance is not required.

A nurse is providing teaching to a client who is preoperative prior to a transurethral resection of the prostate (TURP). Which of the following statements indicates an understanding of the information? A. "I will not need to have a urinary catheter following this procedure." B. "I will expect my urine to be cloudy after having this procedure." C. "At least I won't have leakage of urine after having this procedure." D. "I will feel the urge to urinate following this procedure."

D. "I will feel the urge to urinate following this procedure." After a TURP, the client will feel the urge to urinate. The nurse should reassure him that he will receive analgesics to help relieve this discomfort. The client will require an indwelling urinary catheter following a TURP to monitor urine output and bleeding. Cloudy urine can be a manifestation of retrograde ejactulation or infection. The client should report cloudy urine to the provider. The client might have temporary dribbling and leakage of urine following a TURP. The nurse should reassure the client that the manifestations will resolve.

A nurse is teaching a client who has a spinal cord injury to perform intermittent urinary self-catheterization at home after discharge. Which of the following statements indicates that the client understands the procedure? A. "I'll drink less water so I don't have to catheterize myself too often." B. "I must use the sterile technique for each of the catheterizations." C. "I should stop the catheterization when I have removed 150 mL of urine." D. "I will perform intermittent self-catheterization every 2 to 3 hr."

D. "I will perform intermittent self-catheterization every 2 to 3 hr." The client might initially require self-catheterization every 2 to 3 hours, with the frequency eventually increasing to every 4 to 6 hours. A longer interval can result in bladder distention and an increased risk of urinary tract infections. The client can self-catheterization as often as needed and should drink at least 2 to 2.5 L of fluid to make sure a sufficient amount of urine is produced to flush the bladder adequately. A Client performing intermittent self-catheterization at home uses a clean (Not sterile) technique. EBP indicates that clients using a clean techniques in their own homes are at no greater risk of infection because they have acclimated to the bacterial environment of their homes. The client should empty the bladder completely with each catheterization, as urine that remains for l9onger periods of time in the bladder increases the client's risk of a UTI.

A nurse is reinforcing teaching with a client who has acute pyelonephritis. Which of the following instructions should the nurse include in the teaching? A. "You should avoid taking NSAIDs for pain." B. "You should maintain complete bed rest until the manifestations decrease." C. "You should drink 1,000ml of fluid per day." D. "You should complete the entire cycle of antibiotic therapy."

D. "You should complete the entire cycle of antibiotic therapy." The client should complete the full prescription of the antibiotic therapy to decrease the chance of regrowth of the causative

A nurse is assessing a client who is receiving peritoneal dialysis. which of the following findings should the nurse report to the provider immediately? A. Difficulty draining the effluent B. Redness at the access site C. Fluid flowing from the catheter site D. Cloudy effluent

D. Cloudy effluent A cloudy or opaque effluent indicates the client is at high risk for peritonitis, a bacterial infection of the peritoneum. Therefore, this is the priority finding for the nurse to report to the provider.

A nurse is teaching a client who is preoperative for a cystoscopy. Which of the following statements should the nurse make? A. You will need to keep the sutures clean after this procedure B. You will be placed on your left side for this procedure C. Expect to be on bed rest for 24 hr after this procedure D. Expect to have pink-tinged urine after this procedure

D. Expect to have pink-tinged urine after this procedure A cystoscopy is a procedure in which a scope is inserted into the urethra to diagnose or treat bladder problems. Following the procedure, pink-tinged urine is expected.

A nurse is reviewing the laboratory findings of a client who has chronic kidney disease. The client reports significant, persistent nausea and muscle weakness. Which of the findings should the nurse expect? A. Hypernatremia B. Hypomagnesemia C. Hypercalcemia D. Hyperkalemia

D. Hyperkalemia A Client who has chronic kidney disease can have a hyperkalemia, which is a potassium level greater than 5.0mEq/L. The expected reference range for a potassium level is 3.5 to 5.0 mEq/L. Other manifestations of hyperkalemia can include palpitation, dysrhythmias, nausea, and muscle weakness.

A nurse is collecting data from a client who has acute kidney injury (AKI). According to the RIFLE classification system, which of the following findings should the nurse identify as an indication that the client has end-stage kidney disease? A. Less than 0.5 mL/kg of urine output for 12 hours B. No urine output for 12 hours C. No urine output without renal replacement therapy for 4 to 12 weeks D. No urine output without renal replacement therapy for more than 3 months

D. No urine output without renal replacement therapy for more than 3 months In the RIFLE classification, R is for Risk, I is for Injury, F is for Failure, L is for Loss, and E is for End-stage kidney disease. No urine output without renal

A nurse is checking the Lab Values of a client who has chronic kidney disease. The nurse should expect evaluations in which of the following values? A. Calcium and bicarbonate B. Arterial pH and PaCO2 C. Hemoglobin and Hematocrit D. Potassium and Magnesium

D. Potassium and Magnesium Clients who have CKD have hyperkalemia. Hypophosphatemia, and hypermagnesemia as well as elevation in serum creatinine and blood urea nitrogen

A nurse is collecting data from a client who has an injury to the lower abdomen following a motor-vehicle crash. The nurse should identify that which of the following findings is a manifestations of bladder trauma? a. Hematuria b. Pyuria c. Fever d. Stress incontinence

a. Hematuria Manifestations of bladder trauma include hematuria, or blood in the urine; blood at the urinary meatus; pelvic pain; and anuria, or the absence of urine.

A nurse is caring for a client who has a diagnosis of renal calculi and reports severe flank pain. Which of the following is the priority nursing action? a. relieve the client's pain b. encourage the client to increase fluid intake c. encourage the client to increase fluid intake c. monitor the client's I & Od. strain the client's urine

a. relieve the client's pain Using the urgent versus non-urgent priority-setting framework, the nurse should consider urgent needs to be the priority because they pose a greater threat to the client. The nurse might also need to use Maslow's hierarchy of needs, the ABC priority-setting framework, and/or nursing knowledge to identify which finding is the most urgent. The pain associated with renal calculi is severe and can lead to shock; therefore, this is the priority action.

A nurse is collecting data from a client who is 1 week postoperative following a living donor kidney transplant. Which of the following findings should indicate to the nurse that the client is experiencing acute kidney rejection? a) Creatinine 0.8 mg/dL b) Blood pressure 160/90 mmHg c) Sodium 137 mg/dL d) Urinary output 100 ml/hr

b) Blood pressure 160/90 mmHg Due to the kidney's role in fluid and blood pressure regulation, a client who is experiencing rejection can have hypertension. Manifestations of acute kidney rejection can include: - Increase in serum creatinine - Increase in sodium - Decreased urine output, anuria, oliguria (<30 ml/hr) - Weight gain

A nurse is caring for a client who is receiving peritoneal dialysis. The nurse notes that the dialysate output is less than the input, and the client's abdomen is distended. Which of the following actions should the nurse take? a. Insert an indwelling urinary catheter. b. Change the client's position. c. Administer pain medication to the client. d. Place the drainage bag above the client's abdomen.

b. Change the client's position. The client is retaining the dialysate solution after the dwell time. The nurse should ensure that the clamp is open and the tubing is not kinked, and reposition the client to facilitate the drainage of the solution from the peritoneal cavity. Peritoneal dialysis is used for clients who have acute or chronic kidney disease. An indwelling urinary catheter will not relieve the client's discomfort. The client is retaining the dialysate solution after the dwell time. Pain medication will not correct the cause of the client's discomfort. The nurse should position the drainage bag lower than the client's abdomen to promote gravity drainage.

A nurse is reinforcing teaching with a newly licensed nurse about caring for a client who has a new left arteriovenous fistula. Which of the following statements should the nurse make? a.Instruct the client to restrict movement of his left arm b.Avoid taking blood pressures on the client's left arm c. Check the fistula daily for a vibration d. Instruct the client to sleep on his left side.

b.Avoid taking blood pressures on the client's left arm The nurse should avoid taking blood pressure measurements on the client's left arm, which can decrease blood flow and cause clotting.

A nurse is caring for a client who had a nephrostomy tube inserted 8 hours ago. which of the following actions should the nurse include in the client's plan of care? a. Flush the nephrostomy tube every 4 hours with sterile water. b. Clamp the nephrostomy tube intermittently to establish continence c. Check the skin at the nephrostomy site for irritation from urine leakage. d. Monitor for and report any blood-tinged drainage to the provider immediately

c. Check the skin at the nephrostomy site for irritation from urine leakage. The nurse should monitor the client for complications (bleeding, hematuria, fistula formation, infection), impairment of skin integrity (inflammation, infection, bleeding, urine leakage, irritation), and tube obstruction. The nurse should use the aseptic technique for dressing changes and encourage oral intake but should never clamp or irrigate the nephrostomy tube without a specific prescription to do so.

A nurse is assessing a client who is receiving hemodialysis for the first time. which of the following findings indicates that the client is developing dialysis disequilibrium syndrome (DDS)? a. elevated BUN b. bradycardia c. headache d. temperature 39.2 (102.5)

c. headache DDS is a CNS disorder that can develop in clients who are new to dialysis due to the rapid removal of solutes and changes in the blood pH. clients beginning hemodialysis are at greatest risk, particularly if their BUN is above 175. DDS causes headaches, nausea, vomiting, a decreased level of consciousness, seizures, and restlessness. when the condition is severe, clients progress to confusion, seizures, coma, and death

A nurse is assessing a client who is postoperative following a transurethral resection of the prostate (TURP) and has continuous bladder irrigation. The nurse notes no drainage in the client's urinary drainage bag over 1 hr. Which of the following actions should the nurse take? a. Instruct the client to attempt to void around the indwelling urinary catheter b. Increase the rate of irrigation fluid instillation c. Irrigate the indwelling urinary catheter with a syringe d. prepare to administer a diuretic

c. irrigate the indwelling urinary catheter with a syringe. No drainage in the urinary drainage bag indicates an obstruction. The nurse should gently irrigate the indwelling urinary catheter as prescribed to clear the obstruction and allow urine and irrigating fluid to drain. The nurse should instruct the client to avoid trying to urinate around the urinary catheter because this can cause bladder spasms. The nurse should not increase the rate of irrigation fluid because no drainage in the urinary drainage bag indicates an obstruction of the indwelling urinary cathter. Increasing the rate of instillation can put additional pressure on the client's bladder. The nurse should not administer a diuretic to the client because no drainage indicates an obstruction of the indwelling urinary catheter.

A nurse is teaching a newly licensed nurse about collecting a 24 hour urine specimen for creatinine clearance. which of the following instructions should the nurse include? a. include the first void specimen at the start of the collection period. b. discard the last voided specimen at the end of the collection period c. place signs in the bathroom as a reminder about the test in progress d. instruct the client to increase exercise during the 24 hour period

c. place signs in the bathroom as a reminder about the test in progress The nurse should place signs in the bathroom and alert family members of the test in progress so that everyone saves the specimens appropriately throughout the test.