Chapter 26: Nursing Assessment: Renal and Urinary Tract Function
The nurse is preparing a client for a nuclear scan of the kidneys. Following the procedure, the nurse instructs the client to
drink liberal amounts of fluids. Explanation: After the procedure is completed, the client is encouraged to drink fluids to promote excretion of the radioisotope by the kidneys. The remaining instructions are not associated with a nuclear scan.
A kidney biopsy has been scheduled for a patient with a history of acute renal failure. The patient asks the nurse why this test has been scheduled. What is the nurse's best response?
"A biopsy is sometimes necessary for diagnosing and evaluating the extent of kidney disease." Explanation: Biopsy of the kidney is used in diagnosing and evaluating the extent of kidney disease. Indications for biopsy include unexplained acute renal failure, persistent proteinuria or hematuria, transplant rejection, and glomerulopathies.
A female client presents to the health clinic for a routine physical examination. The nurse observes that the client's urine is bright yellow. Which question is most appropriate for the nurse to ask the client?
"Do you take multiple vitamin preparations?" Explanation: Urine that is bright yellow is an anticipated abnormal finding in the client taking a multivitamin preparation. Urine that is orange may be caused by intake of phenytoin or other medications. Orange- to amber-colored urine may also indicate concentrated urine due to dehydration or fever. Urine that is pink to red may indicate lower urinary tract bleeding. Yellow to milky white urine may indicate infection, pyuria, or, in the female client, the use of vaginal creams.
A nurse is collecting a health history on a client who's to undergo a renal angiography. Which statement by the client should be the priority for the nurse to address?
"I'm allergic to shellfish." Explanation: An allergy to iodine, shellfish, or other seafood should immediately be investigated because the contrast agent used in the procedure may contain iodine, which can cause a severe allergic reaction. Although contrast agents should be used cautiously in clients with diabetes mellitus, investigating this isn't the nurse's priority if the client also has a shellfish allergy. It's appropriate for the client to not eat after midnight before the procedure. The client's hypertension isn't a priority because this condition is the likely reason the renal angiography was ordered.
The nurse received report on a hospitalized patient who was being evaluated for renal disease. The nurse was told that the patient had oliguria. Select the output record that would be consistent with that diagnosis.
350 mL/24 hr Explanation: Oliguria refers to an output of less than 400 mL/day.
The nurse is completing a full exam of the client's renal system. Which assessment finding best documents the need to offer the use of the bathroom?
A dull sound when percussing over the bladder Explanation: A dull sound when percussing over the bladder indicates a full bladder. Because the bladder is full, the nurse would offer for the client to use the bathroom. Tenderness over the kidney can indicate an infection or stones. Bruits are an abnormal vascular sound that does not indicate the need to use the bathroom. Ingesting water does not mean that the client has to void at this time.
A patient has an increase in blood osmolality when the nurse reviews the laboratory work. What can this increase indicate for the patient?
ADH stimulation Explanation: Antidiuretic hormone (ADH), also known as vasopressin, is a hormone that is secreted by the posterior portion of the pituitary gland in response to changes in osmolality of the blood. With decreased water intake, blood osmolality tends to increase, stimulating ADH release.
Which hormone causes the kidneys to reabsorb sodium?
Aldosterone Explanation: Aldosterone is a hormone synthesized and released by the adrenal cortex. Antidiuretic hormone is secreted by the posterior pituitary gland. Growth hormone and prostaglandins do not cause the kidneys to reabsorb sodium.
Which of the following diagnostic tests would the nurse expect to be ordered to determine the details of the arterial supply to the kidneys?
Angiography Explanation: Angiography provides the details of the arterial supply to the kidneys, specifically the number and location of renal arteries. Radiography shows the size and position of the kidneys, ureters, and bladder. A CT scan is useful in identifying calculi, congenital abnormalities, obstruction, infections, and polycystic diseases. Cystoscopy is used for providing a visual examination of the internal bladder. Reference:
A patient has undergone a renal biopsy. After the test, while the patient is resting, the patient reports severe pain in the back, arms, and shoulders. Which intervention should be offered by the nurse?
Assess the patient's back and shoulder areas for signs of internal bleeding. Explanation: After a renal biopsy, the patient is on bed rest. It is important to assess the dressing frequently for signs of bleeding and evaluate the type and severity of pain. Severe pain in the back, shoulder, or abdomen may indicate bleeding. In such a case, the nurse should notify the physician about these signs and symptoms. Distracting the patient's attention, helping the patient to sit up or ambulate, and providing analgesics may only aggravate the patient's pain and, therefore, should not be performed by the nurse.
A patient is having a problem with retention of urine in the bladder. Which of the following diagnostic tests measures the amount of residual urine in the bladder?
Bladder ultrasonography Explanation: A bladder ultrasonography is a noninvasive method of measuring urine volume in the bladder; automatic calculations display the urine volume. A nuclear scan provides information about kidney perfusion and function. It is used to evaluate acute and chronic renal failure. Cystography aids in evaluating vesicourethral reflux and in assessing bladder injury. IV urography provides an approximate estimate of renal function and may be used as the initial assessment of many urologic problems.
A 24-year-old patient was admitted to the emergency room after a water skiing accident. The X-rays revealed two fractured vertebrae, T-12 and L1. Based on this information, the nurse would know to perform which of the following actions?
Check the patient's urine for hematuria. Explanation: The kidneys are located from the 12th thoracic vertebrae to the third lumbar vertebrae. Therefore, the accident may have caused blunt force trauma damage to the kidneys. Ice is always applied for the first 24 hours, then heat, if not contraindicated. Activity will be restricted but bed rest is not necessary.
When describing the functions of the kidney to a client, which of the following would the nurse include?
Control of water balance Explanation: Functions of the kidneys include control of water balance and blood pressure, regulation of red blood cell production, synthesis of vitamin D to active form, and secretion of prostaglandins.
A creatinine clearance test is ordered for a client with possible renal insufficiency. The nurse must collect which serum concentration midway through the 24-hour urine collection?
Creatinine Explanation: To calculate creatinine clearance, a 24-hour urine specimen is collected. The serum creatinine concentration is measured midway through the collection. The other concentrations are not measured during this test.
The nurse is providing preprocedure teaching about an ultrasound. The nurse informs the patient that, in preparation for an ultrasound of the lower urinary tract, the patient will require what?
Increased fluid intake to produce a full bladder Explanation: Ultrasonography requires a full bladder; therefore, fluid intake should be encouraged before the procedure. The administration of a radiopaque contrast agent is required to perform IV urography studies, such as an IV pyelogram. Ultrasonography is a quick and painless diagnostic test and does not require sedation or intubation. The injection of a radioisotope is required for nuclear scan, and ultrasonography is not in this category of diagnostic studies.
A client is scheduled for a renal angiography. Which of the following would be appropriate before the test?
Monitor the client for an allergy to iodine contrast material. Explanation: A renal angiography procedure will be contraindicated if the client is allergic to iodine contrast material. Therefore, it is important for the nurse to monitor the client for an allergy to iodine contrast material. The nurse monitors the client for the signs of electrolyte and water imbalance, mental changes, and periorbital edema at any time regardless of the test being done.
The nurse is caring for a client scheduled for urodynamic testing. Following the procedure, which information does the nurse provide to the client?
"Contact the primary provider if you experience fever, chills, or lower back pain." Explanation: The client must be made aware of the signs of a urinary tract infection after the procedure. The client should contact the primary provider if fever, chills, lower back pain, or continued dysuria and hematuria occur. The client will have catheters placed during the procedure but will not be sent home with one. The client should be told to avoid caffeinated, carbonated, and alcoholic beverages after the procedure because these can further irritate the bladder. These symptoms usually decrease or subside by the day after the procedure. If the client received an antibiotic medication before the procedure, they should be told to continue taking the complete course of medication after the procedure. This is a measure to prevent infection.
The nurse is preparing the client for magnetic resonance imaging (MRI) of the kidney. Which statement by the client requires action by the nurse?
"I took my blood pressure medication with my morning coffee an hour ago." Explanation: The client should not eat for at least 1 hour before an MRI. Alcohol, caffeine-containing beverages, and smoking should be avoided for at least 2 hours before an MRI. The client can take his or her usual medications except for iron supplements prior to the procedure.
The nurse is preparing to conduct intermittent catheterization of an older adult who has been retaining urine due to benign prostatic hyperplasia (BPH). The nurse would understand that the patient's bladder was filled beyond its normal capacity if catheterization yielded how many mL of urine? Select all that apply. -250 mL -450 mL -650 mL -850 mL -1,050 mL
-650 mL -850 mL -1,050 mL Explanation: Normal bladder capacity is around 30 to 500 mL of urine.
A patient had a renal angiography and is being brought back to the hospital room. What nursing interventions should the nurse carry out after the procedure to detect complications? Select all that apply. -Assess peripheral pulses. -Compare color and temperature between the involved and uninvolved extremities. -Examine the puncture site for swelling and hematoma formation. -Apply warm compresses to the insertion site to decrease swelling. -Increase the amount of IV fluids to prevent clot formation.
-Assess peripheral pulses. -Compare color and temperature between the involved and uninvolved extremities. -Examine the puncture site for swelling and hematoma formation. Explanation: After the procedure, vital signs are monitored until stable. If the axillary artery was the injection site, blood pressure measurements are taken on the opposite arm. The injection site is examined for swelling and hematoma. Peripheral pulses are palpated, and the color and temperature of the involved extremity are noted and compared with those of the uninvolved extremity. Cold compresses may be applied to the injection site to decrease edema and pain.
The nurse is reviewing the client's lab results. Which lab result requires follow up by the nurse? Select all that apply. -Urine: RBC 20 -BUN 28 mg/dL -Urine: WBC 1 -Serum creatinine 0.8 mg/dL -Urine specific gravity 1.020
-Urine: RBC 20 -BUN 28 mg/dL Explanation: Hematuria (> 3RBCs) and an elevated BUN are both suggestive of a problem within the genitourinary tract. A serum creatinine of 0.8 mg/dL and a urine specific gravity of 1.020 are within normal limits. A rare white blood cell is not clinically significant.
When fluid intake is normal, the specific gravity of urine should be:
1.010 to 1.025 Explanation: Urine-specific gravity is a measurement of the kidneys' ability to concentrate urine. The specific gravity of water is 1.000. A urine-specific gravity less than 1.010 may indicate inadequate fluid intake. A urine-specific gravity greater than 1.025 may indicate dehydration.
When fluid intake is normal, the specific gravity of urine should be
1.010 to 1.025. Explanation: Urine-specific gravity is a measurement of the kidneys' ability to concentrate urine. The specific gravity of water is 1.000. A urine-specific gravity less than 1.010 may indicate inadequate fluid intake. A urine-specific gravity greater than 1.025 may indicate overhydration.
A nurse is caring for a 73-year-old male patient with a urethral obstruction related to prostatic enlargement. The nurse is aware this may result in what?
A urinary tract infection (UTI) Explanation: An obstruction of the bladder outlet, such as in advanced benign prostatic hyperplasia, results in abnormally high voiding pressure with a slow, prolonged flow of urine. The urine may remain in the bladder, which increases the potential of a UTI. Older male patients are at risk for prostatic enlargement, which causes urethral obstruction and can result in hydronephrosis, renal failure, and UTIs.
The nurse is conducting a focused assessment of a male patient who has a history of poorly controlled hypertension. Which of the following findings would indicate the presence of renal artery bruits?
A whooshing sound over the kidneys Explanation: A whooshing sound is indicative of a bruit. Gurgles, clicks, heart sounds, and an absence of audible sounds are not associated with a bruit.
The nurse is caring for a client after a cystoscopic examination. Following the procedure, the nurse informs the client that which effect may occur?
Blood-tinged urine Explanation: Postprocedural management is directed at relieving any discomfort resulting from the examination. Some burning upon voiding, blood-tinged urine, and urinary frequency from trauma to the mucous membranes can be expected. Moist heat to the lower abdomen and warm Sitz baths are helpful in relieving pain and relaxing the muscles. Not eating and diarrhea are not expected following a cystoscopic examination. The client should not experience severe abdominal pain.
A patient is being seen in the clinic for possible kidney disease. What major sensitive indicator of kidney disease does the nurse anticipate the patient will be tested for?
Creatinine clearance level Explanation: Creatinine is an endogenous waste product of skeletal muscle that is filtered at the glomerulus, passed through the tubules with minimal change, and excreted in the urine. Hence, creatinine clearance is a good measure of the glomerular filtration rate (GFR), the amount of plasma filtered through the glomeruli per unit of time. Creatinine clearance is the best approximation of renal function. As renal function declines, both creatinine clearance and renal clearance (the ability to excrete solutes) decrease.
A client has undergone diagnostic testing that involved the insertion of a lighted tube with a telescopic lens. The nurse identifies this test as which of the following?
Cystoscopy Explanation: Cystoscopy is the visual examination of the inside of the bladder using an instrument called a cystoscope, a lighted tube with a telescopic lens. Renal angiography involves the passage of a catheter up the femoral artery into the aorta to the level of the renal vessels. Intravenous pyelography or excretory urography is a radiologic study that involves the use of a contrast medium to evaluate the kidneys' ability to excrete it.
Following a voiding cystogram, the client has a nursing diagnosis of risk for infection related to the introduction of bacterial following manipulation of the urinary tract. An appropriate nursing intervention for the client is to:
Encourage high fluid intake. Explanation: A voiding cystogram involves the insertion of a urinary catheter, which can result in the introduction of microorganism into the urinary tract. Fluid intake is encouraged to flush the urinary tract and promote removal of microorganisms. Monitoring for hematuria, applying heat, and straining urine do not address the nursing diagnosis of risk for infection.
The nurse is instructing a 3-year-old's parent regarding abnormal findings within the urinary system. Which assessment finding would the nurse document as a normal finding for this age group?
Enuresis Explanation: The nurse would be most correct to document that enuresis, the involuntary voiding during sleep or commonly called "wetting the bed," is a normal finding in a pediatric client younger than 5 years old. Dysuria (pain on urination), hematuria (red blood cells in urine), and anuria (urine output less than 50 mL/day) are all abnormal findings needing further investigation.
The nurse is caring for a patient suspected of having renal dysfunction. When reviewing laboratory results for this patient, the nurse recalls that several substances are filtered from the blood by the glomerulus and these substances are then excreted in the urine. The nurse identifies the presence of which substances in the urine as abnormal findings?
Glucose and protein Explanation: The various substances normally filtered by the glomerulus, reabsorbed by the tubules, and excreted in the urine include sodium, chloride, bicarbonate, potassium, glucose, urea, creatinine, and uric acid. Within the tubule, some of these substances are selectively reabsorbed into the blood. Glucose is completely reabsorbed in the tubule and normally does not appear in the urine. However, glucose is found in the urine if the amount of glucose in the blood and glomerular filtrate exceeds the amount that the tubules are able to reabsorb. Protein molecules are also generally not found in the urine because amino acids are also filtered at the level of the glomerulus and reabsorbed so that it is not excreted in the urine.
A nurse is reviewing the laboratory test results of a client with renal disease. Which of the following would the nurse expect to find?
Increased serum creatinine Explanation: In clients with renal disease, the serum creatinine level would be increased. The BUN also would be increased, serum albumin would be decreased, and potassium would likely be increased.
Urine specific gravity is a measurement of the kidney's ability to concentrate and excrete urine. Specific gravity compares the density of urine to the density of distilled water. Which is an example of how urine concentration is affected?
On a hot day, a person who is perspiring profusely and taking little fluid has low urine output with a high specific gravity. Explanation: Specific gravity is altered by the presence of blood, protein, and casts in the urine and is normally influenced primarily by hydration status. On a hot day, a person who is perspiring profusely and taking little fluid has low urine output with a high specific gravity. A person who has a high fluid intake and who is not losing excessive water from perspiration, diarrhea, or vomiting has copious urine output with a low specific gravity. When the kidneys are diseased, the ability to concentrate urine may be impaired, and the specific gravity remains relatively constant.
Which of the following is an age-related change associated with the renal system?
Renal arteries thicken Explanation: Age-related changes include thickening of the renal arteries, a decrease in the weight of the kidney, blood flow decrease by approximately 10% per decade, and decreased bladder capacity.
Which nursing assessment finding indicates the client has not met expected outcomes?
The client voids 75 cc four hours post cystoscopy. Explanation: Urinary retention is an undesirable outcome following cystoscopy. A pain rating of 3 is an achievable and expected outcome following kidney biopsy. Blood-tinged urine is an expected finding following cystoscopy due to trauma of the procedure. A client would be expected to eat and retain a meal following an intravenous pyelogram.
The nurse is caring for a client who has presented to the walk-in clinic. The client verbalizes pain on urination, feelings of fatigue, and diffuse back pain. When completing a head-to-toe assessment, at which specific location would the nurse assess the client's kidneys for tenderness?
The costovertebral angle Explanation: The nurse is correct to assess the kidneys for tenderness at the costovertebral angle. The other options are incorrect.
The nurse is caring for a client who is brought to the emergency department after being found unconscious outside in hot weather. Dehydration is suspected. Baseline lab work including a urine specific gravity is ordered. Which relation between the client's symptoms and urine specific gravity is anticipated?
The specific gravity will be high. Explanation: The nurse assesses all of the data to make an informed decision on client status. On a hot day, the client found outside will be perspiring. When dehydration occurs, a client will have low urine output and increased specific gravity of urine. Normal specific gravity is inversely proportional. The density of distilled water is one. A low specific gravity is noted in a client with high fluid intake and who is not losing systemic fluid.
A group of students is reviewing for a test on the urinary and renal system. The students demonstrate understanding of the information when they identify which of the following as part of the upper urinary tract?
Ureters Explanation: The upper urinary tract is composed of the kidneys, renal pelvis, and ureters. The lower urinary tract consists of the bladder, urethra, and pelvic floor muscles.
A client in a short-procedure unit is recovering from renal angiography in which a femoral puncture site was used. When providing postprocedure care, the nurse should:
check the client's pedal pulses frequently. Explanation: 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 should leave this dressing in place for several hours — and only remove it if instructed to do so.
The nurse is preparing a client for a nuclear scan of the kidneys. Following the procedure, the nurse instructs the client toThe nurse is preparing a client for a nuclear scan of the kidneys. Following the procedure, the nurse instructs the client to
drink liberal amounts of fluids. Explanation: After the procedure is completed, the client is encouraged to drink fluids to promote excretion of the radioisotope by the kidneys. The remaining instructions are not associated with a nuclear scan.
When the bladder contains 400 to 500 mL of urine, this is referred to as
functional capacity. Explanation: A marked sense of fullness and discomfort, with a strong desire to void, usually occurs when the bladder contains 400 to 500 mL of urine, referred to as the "functional capacity." Anuria is a total urine output less than 50 mL in 24 hours. Specific gravity reflects the weight of particles dissolved in the urine. Renal clearance refers to the ability of the kidneys to clear solutes from the plasma.
A client is experiencing some renal secretion abnormalities, for which diagnostics are being performed. Which substance is typically reabsorbed in urine?
glucose Explanation: Amino acids and glucose typically are reabsorbed and not excreted in the urine. The filtrate that is secreted as urine usually contains water, sodium, chloride, bicarbonate, potassium, urea, creatinine, and uric acid.
A client with a history of bladder retention hasn't voided for 8 hours. A nurse concerned that the client is retaining urine notifies the physician. He orders a bladder ultrasonic scan and placement of an indwelling catheter if the residual urine is greater than 350 mL. The nurse knows that using the bladder ultrasonic scan to measure residual urine instead of placing a straight catheter reduces the risk of:
microorganism transfer. Explanation: Bladder ultrasonic scanning, a noninvasive way of calculating the amount of urine in the bladder, reduces the risk of transferring microorganisms into the bladder. Use of a straight catheter to measure residual urine increases the transfer of microorganisms into the bladder, and increases, rather than reduces, client discomfort. A bladder ultrasonic scan doesn't reduce the risk of prostate irritation or incorrect urine output values.
A client presents to the emergency department complaining of a dull, constant ache along the right costovertebral angle along with nausea and vomiting. The most likely cause of the client's symptoms is:
renal calculi. Explanation: Renal calculi usually presents as a dull, constant ache at the costovertebral angle. The client may also present with nausea and vomiting, diaphoresis, and pallor. The client with an overdistended bladder and interstitial cystitis presents with dull, continuous pain at the suprapubic area that's intense with voiding. The client also complains of urinary urgency and straining to void. The client with acute prostatitis presents with a feeling of fullness in the perineum and vague back pain, along with frequency, urgency, and dysuria.
