Genitourinary Disorders
Which interventions should the nurse include when preparing a teaching plan for the client diagnosed with chronic prostatitis? Select all that apply. 1. Sit in a warm sitz bath for 10 to 20 minutes several times daily. 2. Sit in the chair with the feet elevated for 2 hours daily. 3. Drink at least 3,000 mL of oral fluids, especially tea and coffee, daily. 4. Stop broad-spectrum antibiotics as soon as the symptoms subside. 5. Take nonsteroidal anti-inflammatory medications for pain.
1 and 5 1. The client should sit in a warm sitz bath for 10 to 20 minutes several times each day to provide comfort and assist with healing. 5. Nonsteroidal anti-inflammatory medications such as ibuprofen or naproxen can relieve pain
The client diagnosed with CKD has a new arteriovenous fistula in the left forearm. Which intervention should the nurse implement? Select all that apply. 1. Teach the client to carry heavy objects with the right arm. 2. Perform all laboratory blood tests on the left arm. 3. Instruct the client to lie on the left arm during the night. 4. Discuss the importance of not performing any hand exercises. 5. Have the client wash the area with soap and warm water daily.
1 and 5. 1. Carrying heavy objects in the left arm could cause the fistula to clot by putting undue stress on the site, so the client should carry objects with the right arm. 5. The client should wash the area around the access daily with soap and warm water and observe for signs of infection
The nurse is preparing the plan of care for a client diagnosed with fluid volume deficit. Which interventions should the nurse include in the plan of care? Select all that apply. 1. Monitor vital signs every 2 hours until stable. 2. Measure the client's oral intake and urinary output daily. 3. Administer mouth care when bathing the client. 4. Weigh the client weekly in the same clothing at the same time. 5. Assess skin turgor and mucous membranes every shift.
1 and 5. 1. Vital signs should be monitored every 2 hours until stable and more frequently if the client is unstable. 5. Skin turgor and mucous membranes should be assessed every shift or more often depending on the client's condition.
The client diagnosed with a fluid and electrolyte disturbance in the emergency department is exhibiting peaked T waves on the STAT electrocardiogram (EKG). Which interventions should the nurse implement? Rank in order of priority. 1. Assess the client for leg and muscle cramps. 2. Check the serum potassium level. 3. Notify the health-care provider. 4. Arrange for a transfer to the telemetry floor. 5. Administer polystyrene sulfonate.
1, 2, 3, 5, 4. 1. The nurse should assess to determine if the client is symptomatic of hyperkalemia. 2. A peaked T wave is indicative of hyperkalemia; therefore, the nurse should obtain a potassium level. 3. Hyperkalemia is a life-threatening situation because of the risk of cardiac dysrhythmias; therefore, the nurse should notify the HCP. 5. Polystyrene sulfonate (Kayexalate), a cation resin, will help remove potassium through the gastrointestinal system and should be administered to decrease the potassium level. 4. The client should be monitored continuously for cardiac dysrhythmias, so a transfer to the telemetry unit is warranted.
Which intervention should the nurse include when assessing the client for urinary retention? Select all that apply. 1. Inquire if the client has the sensation of fullness. 2. Percuss the suprapubic region for a dull sound. 3. Scan the bladder with the ultrasound scanner. 4. Palpate from the umbilicus to the suprapubic area. 5. Auscultate the two lower abdominal quadrants.
1, 2, 3, and 4. 1. The nurse needs to assess the client's sensation of needing to void or feeling of fullness. 2. A dull sound heard when percussing the bladder indicates it is filled with urine. 3. A portable bladder scan is used to assess for the presence of urine rather than using a straight catheter. 4. A distended bladder can be palpated.
The nurse is caring for a 1-year-old client diagnosed with chronic pyelonephritis. Which assessment data support the diagnosis of chronic pyelonephritis? Select all that apply. 1. Fever. 2. Flank pain. 3. Failure to thrive. 4. Fifth disease. 5. Hypertension.
1, 2, 3, and 5. 1. Fever can be noted in children diagnosed with chronic pyelonephritis. 2. Flank pain or dysuria are clinical manifestations of chronic pyelonephritis. 3. Failure to thrive may be noted in young children with a diagnosis of chronic pyelonephritis. 5. Some children with chronic pyelonephritis can be hypertensive
The nurse identifies the concepts of elimination and immunity for a female client diagnosed with a UTI. Which discharge instructions should the nurse provide the client? Select all that apply. 1. Teach the client to wipe from front to back after voiding. 2. Encourage the client to drink cranberry juice each morning. 3. Inform the client that frequent episodes of incontinence are expected. 4. Discuss the clinical manifestations of a recurrent infection. 5. Have the client fill a container of water to sip until at least 2,000 mL are consumed. 6. Request that the client sit in a tub of warm water twice a day for 25 minutes.
1, 2, 4, and 5. 1. A female client should be taught to wipe the meatus and vaginal area from front to back to avoid contaminating the urethra (urinary orifice) with fecal matter. 2. Cranberry juice is acidic and changes the pH of the urine, making the environment less conducive to bacterial growth. 4. The client should be taught about the clinical manifestations of a UTI so she can know when to notify the HCP. 5. The client should increase the intake of water to at least 2000 mL/24 hours in order to flush the bacteria from the urinary system.
The client is diagnosed with AKI. Which clinical manifestations indicate to the nurse the client is in the recovery period? Select all that apply. 1. Increased alertness and no seizure activity. 2. Increase in hemoglobin and hematocrit. 3. Denial of nausea and vomiting. 4. Decreased urine-specific gravity. 5. Increased serum creatinine level.
1, 2, and 3. 1. AKI affects almost every system in the body. Neurologically, the client may have drowsiness, headache, muscle twitching, and seizures. In the recovery period, the client is alert and has no seizure activity. 2. In renal failure, levels of erythropoietin are decreased, leading to anemia. An increase in hemoglobin and hematocrit indicates the client is in the recovery period. 3. Nausea, vomiting, and diarrhea are common in the client diagnosed with AKI; therefore, an absence of these indicates the client is in the recovery period.
The client diagnosed with renal calculi is scheduled for a 24-hour urine specimen collection. Which interventions should the RN implement? Select all that apply. 1. Check for the ordered diet and medication modifications. 2. Instruct the client to urinate, and discard this urine when starting a collection. 3. Collect all urine for 24 hours and place it in the appropriate specimen container. 4. Insert an indwelling catheter in the client after having the client empty the bladder. 5. Instruct the UAP to notify the nurse when the client urinates.
1, 2, and 3. 1. The HCP may order certain foods and medications when obtaining a 24-hour urine collection to evaluate for calcium oxalate or uric acid. 2. When the collection begins, the client should completely empty the bladder and discard this urine. The test is started after the bladder is empty. 3. All urine for 24 hours should be saved and put in a container with preservative, refrigerated, or placed on ice as indicated. Not following specific instructions will result in an inaccurate test result.
The client diagnosed with CKD is prescribed hemodialysis on Monday, Wednesday, and Friday. Which interventions should the dialysis nurse implement? Select all that apply. 1. Weigh the client before and after each treatment. 2. Discuss the recommended fluid restriction. 3. Provide potato chips or pretzels as a snack. 4. Monitor the hemodialysis access site continuously. 5. Keep up a lively conversation during the treatments.
1, 2, and 4. 1. These are called the pre- and post-weights. The pre-weight is used to determine the amount of fluid to be removed during the treatment, and the post-weight is used to determine if the goal was met. 2. Clients experiencing renal failure are not processing the fluids in their bodies. Fluid restrictions are prescribed to allow for some fluid so the client does not become dehydrated but limited so the heart is not overtaxed, causing the client to go into heart failure. 4. The client's entire blood supply is being removed from the body and then returned after being filtered. The client could bleed to death in a matter of minutes if the access becomes dislodged.
The client is NPO and is receiving total parenteral nutrition (TPN) via a subclavian line. Which precautions should the nurse implement? Select all that apply. 1. Place the solution on an IV pump at the prescribed rate. 2. Monitor blood glucose every 6 hours. 3. Weigh the client weekly, first thing in the morning. 4. Change the IV tubing every 3 days. 5. Monitor intake and output every shift.
1, 2, and 5. 1. TPN is a hypertonic solution with enough calories, proteins, lipids, electrolytes, and trace elements to sustain life. It is administered via a pump to prevent too rapid infusion. 2. TPN contains a 50% dextrose solution; therefore, the client is monitored to ensure the pancreas is adapting to the high glucose levels. 5. Intake and output are monitored to observe for fluid balance.
The client diagnosed with cancer of the bladder is undergoing intravesical chemotherapy. Which instructions should the nurse provide the client about the procedure? Select all that apply. 1. Instruct the client to restrict fluids 4 hours before the procedure. 2. Teach not to empty the bladder for 1 to 2 hours after the procedure. 3. Explain that the client will need to administer filgrastim at home. 4. Have the client take acetaminophen before coming to the clinic. 5. Tell the client to sit to avoid urine splashing after the procedure.
1, 2, and 5. 1. The client should restrict fluid intake, caffeinated beverages, and the use of diuretics 4 hours prior to the procedure. 2. The client will need to avoid emptying the bladder for 1 to 2 hours after the procedure. 5. After the procedure, for the first void and the next 6 hours, the client should sit to avoid urine splashing, avoid public toilets or urinating outside, and should be taught the use of bleach to clean the toilet after voiding at home (
The nurse is developing a care map for a client diagnosed with chronic kidney disease (CKD) on hemodialysis. Which interrelated concepts should be included in the map? Select all that apply. 1. Fluid and electrolytes. 2. Hematologic regulation. 3. Digestion. 4. Metabolism. 5. Mobility. 6. Nutrition.
1, 2, and 6. 1. The balance of fluids and electrolytes is regulated by the kidneys. 2. Hematologic regulation is an interrelated concept because the client on dialysis does not have a functioning kidney to produce erythropoietin to stimulate the bone marrow to produce red blood cells. In addition, removal of the entire circulating blood three times a week through the dialysis machine places stress on the red blood cells, and they do not last as long as in a nondialyzed body. 6. Nutrition is an issue because the client must adhere to a restricted diet to decrease the number of toxic metabolites not being eliminated through the kidneys.
The nurse is preparing the plan of care for the client diagnosed with a neurogenic flaccid bladder. Which expected outcome is appropriate for this client? 1. The client has conscious control over bladder activity. 2. The client's bladder does not become overdistended. 3. The client has bladder sensation and no discomfort. 4. The client demonstrates how to check for bladder distention.
2. The treatment goal of the flaccid bladder is to prevent overdistention.
The client returned from surgery after having a TURP with cool and clammy skin, and the vitals populated in the flowsheet below. Which interventions should the nurse implement? Select all that apply. Blood Pressure 90/40 100-119 mm Hg systolic 60-80 mm Hg diastolic Temperature 98°F Oral: 98°F (36.7°F) Pulse 110 60-100 beats/min Respirations 24 12-20 breaths/min 1. Assess the urine in the continuous irrigation drainage bag. 2. Decrease the irrigation fluid in the continuous irrigation catheter. 3. Lower the head of the bed while raising the foot of the bed. 4. Contact the surgeon to give an update on the client's condition. 5. Check the client's postoperative creatinine and BUN.
1, 3, and 4. 1. The nurse should assess the drain postoperatively. 3. The head of the bed should be lowered, and the foot should be elevated to shunt blood to the central circulating system. 4. The surgeon needs to be notified of the change in condition.
The nurse is inserting an indwelling catheter into a female client. Which interventions should be implemented? Rank in order of performance. 1. Explain the procedure to the client. 2. Set up the sterile field. 3. Insert the catheter. 4. Place absorbent pads under the client. 5. Clean the perineum with povidone-iodine.
1, 4, 2, 5, 3. 1. The procedure should be explained to the client. 4. Incontinence pads should be placed under the client before beginning the sterile part of the procedure. 2. The sterile field must be set up before cleaning the client's perineum. 5. During the procedure, the perineum is swiped with povidone-iodine (Betadine) or antiseptic swabs from front to back and also down the middle, making only one stroke per swab and discarding after each area (Teas et al., 2018). 3. The catheter should be inserted and the balloon inflated.
The telemetry monitor technician notifies the nurse of the morning telemetry readings. Which client should the nurse assess first? 1. The client in normal sinus rhythm with a peaked T wave. 2. The client diagnosed with atrial fibrillation with a rate of 100. 3. The client diagnosed with a myocardial infarction and occasional PVCs. 4. The client diagnosed with a first-degree atrioventricular block and a rate of 92.
1. A client diagnosed with a peaked T wave could be experiencing hyperkalemia. Changes in potassium levels can initiate cardiac dysrhythmias and instability.
The client with a continent urinary diversion is being discharged. Which discharge instructions should the nurse include in the teaching? 1. Have the client demonstrate catheterizing the stoma. 2. Instruct the client on how to pouch the stoma. 3. Explain the use of a bedside drainage bag at night. 4. Tell the client to call the HCP if the temperature is 99°F or less.
1. A continent urinary diversion is a surgical procedure in which a reservoir is created to hold urine until the client can self-catheterize the stoma. The nurse should observe the client's technique before discharge.
The nurse is caring for a pregnant client diagnosed with acute pyelonephritis. Which scientific rationale supports the client being hospitalized for this condition? 1. The client must be treated aggressively to prevent maternal and fetal complications. 2. The nurse can force the client to drink fluids and avoid nausea and vomiting. 3. The client will be dehydrated, and there won't be sufficient blood flow to the baby. 4. Pregnant clients historically are afraid to take the antibiotics as ordered.
1. A pregnant client diagnosed with a UTI will be admitted for aggressive IV antibiotic therapy to decrease the risk of preterm labor and delivery, septic shock, and other complications. After symptoms subside, the client will be sent home to complete the course of treatment with oral medications.
The client asks, "What does an elevated PSA test mean?" On which scientific rationale should the nurse base the response? 1. An elevated PSA can result from several different causes. 2. An elevated PSA can be only from prostate cancer. 3. An elevated PSA can be diagnostic for testicular cancer. 4. An elevated PSA is the only test used to diagnose BPH.
1. An elevated PSA can be from urinary retention, BPH, prostate cancer, or prostate infarct.
Which statement indicates the client diagnosed with calcium phosphate renal calculi understands the discharge teaching for ways to prevent future calculi formation? 1. "I should increase my fluid intake, especially in warm weather." 2. "I should eat foods containing cocoa and chocolate." 3. "I will walk about a mile every week and not exercise often." 4. "I should take one vitamin a day with extra calcium."
1. An increased fluid intake ensuring 2 to 3 L of urine a day prevents the stone-forming salts from becoming concentrated enough to precipitate.
Which intervention is most important for the nurse to implement for the client with a left nephrectomy? 1. Assess the intravenous fluids for rate and volume. 2. Change the surgical dressing every day at the same time. 3. Monitor the client's PT/PTT/INR level daily. 4. Monitor the percentage of each meal eaten.
1. Assessing the rate and volume of intravenous fluid is the most important intervention for the client with one kidney because an overload of fluids can result in pulmonary edema.
The older client presents to the emergency department reporting burning on urination with an urgency to void, and a temperature of 99.8°F. Which intervention should the nurse implement first? 1. Ask the client to provide a clean voided midstream urine for culture. 2. Insert an 18-gauge peripheral IV catheter and start normal saline fluids. 3. Arrange for the client to be admitted to the medical unit. 4. Initiate the ordered intravenous antibiotic medication.
1. Before the other options are performed, the nurse should have a urine culture specimen sent to the laboratory for culture. A culture is indicated from the symptoms.
The nurse is caring for a client diagnosed with AKI. Which laboratory values are most significant for diagnosing AKI? 1. BUN and creatinine. 2. WBC and hemoglobin. 3. Potassium and sodium. 4. Bilirubin and ammonia level.
1. Blood urea nitrogen (BUN) levels reflect the balance between the production and excretion of urea from the kidneys. Creatinine is a by-product of the metabolism of the muscles and is excreted by the kidneys. Creatinine is the ideal substance for determining renal clearance because it is relatively constant in the body and is the laboratory value most significant in diagnosing kidney injury.
The older client being seen in the clinic reports urinary frequency, urgency, and "leaking." Which priority intervention should the nurse implement when interviewing the client? 1. Ensure communication is nonjudgmental and respectful. 2. Set the temperature for comfort in the examination room. 3. Speak loudly to ensure the client understands the nurse. 4. Ensure the examining room has adequate lighting.
1. Clients with urinary incontinence are often embarrassed, so it is the responsibility of the nurse to approach this subject with respect and consideration.
The nurse is providing discharge teaching to the client diagnosed with polycystic kidney disease. Which statement made by the client indicates the teaching has been effective? 1. "I need to monitor my diet carefully to prevent complications." 2. "I should avoid taking medications for high blood pressure." 3. "When I urinate, there may be blood streaks in my urine." 4. "I may have occasional burning when I urinate with this disease."
1. Diet modification in clients diagnosed with polycystic kidney disease is important to prevent complications from eating foods high in protein, potassium, and phosphorus that are difficult for the kidney to excrete
The client is reporting chills, fever, and left costovertebral pain. Which diagnostic test should the nurse expect the HCP to prescribe first? 1. A midstream urine for culture. 2. A sonogram of the kidney. 3. An intravenous pyelogram for renal calculi. 4. A CT scan of the kidneys.
1. Fever, chills, and costovertebral pain are clinical manifestations of a urinary tract infection (acute pyelonephritis), which requires a urine culture first to confirm the diagnosis.
The nurse and an unlicensed assistive personnel (UAP) are caring for clients on a medical floor. Which nursing task is most appropriate for the registered nurse (RN) to delegate? 1. Collect a clean voided midstream urine specimen. 2. Evaluate the client's 8-hour intake and output. 3. Assist in checking a unit of blood before hanging. 4. Administer a cation-exchange resin enema.
1. Preventing and treating shock with blood and fluid replacement will prevent AKI from hypoperfusion of the kidneys. Significant blood loss is expected in the client diagnosed with a gunshot wound.
Which information indicates to the nurse the client teaching about the treatment of urinary incontinence has been effective? 1. The client prepares a scheduled voiding plan. 2. The client verbalizes the need to increase fluid intake. 3. The client explains how to perform pelvic floor exercises. 4. The client attempts to retain the vaginal cone in place the entire day.
1. Scheduled voiding allows the client to void every 2 to 3 hours, and when the client has remained consistently dry, the interval is increased by about 15 minutes.
The client is admitted to the emergency department after a gunshot wound to the abdomen. Which nursing intervention should the nurse implement first to prevent AKI? 1. Administer normal saline IV. 2. Take vital signs. 3. Place the client on telemetry. 4. Assess abdominal dressing.
1. The UAP can collect specimens. Collecting a midstream urine specimen requires the client to clean the perineal area, to urinate a little, and then collect the rest of the urine output in a sterile container.
The nurse is caring for the client recovering from a percutaneous renal biopsy. Which data indicate the client is complying with client teaching? 1. The client is lying flat in the supine position. 2. The client continues oral fluids restriction while on bedrest. 3. The client uses the bedside commode to urinate. 4. The client refuses to ask for any pain medication.
1. The client needs to lie flat on the back to apply pressure to prevent bleeding.
The client receiving dialysis is reporting being dizzy and light-headed. Which action should the nurse implement first? 1. Place the client in the Trendelenburg position. 2. Turn off the dialysis machine immediately. 3. Bolus the client with 500 mL of normal saline. 4. Notify the health-care provider as soon as possible
1. The nurse should place the client's chair with the head lower than the body, which will shunt blood to the brain; this is the Trendelenburg position.
The female client diagnosed with bladder cancer has a cutaneous urinary diversion and states, "Will I be able to have children now?" Which statement is the nurse's best response? 1. "Cancer does not make you sterile, but sometimes the therapy can." 2. "Are you concerned you can't have children?" 3. "You will be able to have as many children as you want." 4. "Let me have the chaplain come to talk with you about this."
1. This client is asking for information and should be provided with factual information. The surgery will not make the client sterile, but chemotherapy can induce menopause and radiation therapy to the pelvis can render a client sterile.
Which statement indicates discharge teaching has been effective for the postoperative TURP client? 1. "I will call the surgeon if I experience any difficulty urinating." 2. "I will take my finasteride daily, the same as before my surgery." 3. "I will continue restricting my oral fluid intake." 4. "I will take my pain medication routinely even if I do not hurt."
1. This indicates the teaching is effective.
The client diagnosed with CKD is prescribed a 60-gm protein, 2,000-mg sodium diet. Which food choices indicate the client understands the dietary restrictions? 1. A 4-ounce grilled chicken breast, broccoli, and small glass of unsweet tea. 2. Baked potato with chopped ham and sour cream, 12-ounce steak, and beer. 3. Double patty cheeseburger, french fries, and an artificially sweetened beverage. 4. Roast beef sandwich, potato chips, and soft drink.
1. This meal has a small portion of protein and does not contain sodium if the client does not add salt.
The nurse is planning the care of a postoperative client with an ileal conduit. Which intervention should be included in the plan of care? 1. Provide meticulous skin care and pouching. 2. Apply sterile drainage bags daily. 3. Monitor the pH of the urine weekly. 4. Assess the stoma site every day.
1. Urine is acidic, and the abdominal wall tissue is not designed to tolerate acidic environments. The stoma is pouched so the urine will not touch the skin.
Which information regarding the care of a cutaneous ileal conduit should the nurse discuss with the client? 1. Teach the client to instill a few drops of vinegar into the pouch. 2. Tell the client the stoma should be slightly dusky colored. 3. Inform the client that large clumps of mucus are expected. 4. Tell the client it is normal for the urine to be pink or red in color.
1. Vinegar will act as a deodorizing agent in the pouch and help prevent a strong urine smell.
The nurse writes the client problem of "fluid volume excess" (FVE). Which intervention should be included in the plan of care? Select all that apply. 1. Change the IV fluid from 0.9% NS to D5W. 2. Restrict the sodium in the client's diet. 3. Monitor blood glucose levels. 4. Prepare the client for hemodialysis. 5. Weigh the client daily.
2 and 5. 2. Fluid volume excess refers to an isotonic expansion of the extracellular fluid by an abnormal expansion of water and sodium. Therefore, sodium is restricted to allow the body to excrete the extra volume. 5. Obtaining a daily weight is essential to provide information about fluid loss or gain. Each kilogram of weight is equivalent to 1 L of fluid
Which clients should the RN assign to a UAP working on a surgical floor? Select all that apply. 1. The client with a suprapubic catheter inserted yesterday. 2. The client with an indwelling catheter for the past week. 3. The client on a bladder-training regimen. 4. The client being discharged after catheter removal this morning. 5. The client with frequent urinary incontinence.
2, 3, 4, and 5. 2. The UAP can care for a client with an indwelling catheter because adherence to standard precautions is the only requirement for safe client care. 3. The UAP cannot teach bladder training but can implement the strategies for the client on a bladder-training program, such as taking the client to the bathroom at scheduled times. 4. The UAP can care for this client because noting if the client voided after removal of the catheter is within the realm of the UAP's ability. 5. The UAP can care for a client with urinary incontinence.
The nurse is caring for a client diagnosed with CKD. Which antecedents would the nurse assess? Select all that apply. 1. Current diet. 2. Diabetes. 3. Hypertension. 4. Fluid restriction. 5. Race.
2, 3, and 5. 2. Diabetes is a leading cause of CKD caused by the microvascular changes that occur when the blood glucose levels are high. 3. Hypertension is also a leading cause of CKD because hypertension narrows the renal artery and decreases the blood flow to the kidney. 5. Race is an antecedent because genetics are a risk factor for CKD. Non-whites are more at risk for developing CKD, especially when the client has a comorbid condition such as diabetes or hypertension.
Which data support to the nurse the client's diagnosis of acute bacterial prostatitis? Select all that apply. 1. Terminal dribbling. 2. Urinary frequency. 3. Stress incontinence. 4. Sudden fever and chills. 5. Pelvic pain.
2, 4, and 5. 2. Urinary frequency is a sign of an acute or a chronic bacterial prostatitis or a UTI. 4. Clients diagnosed with acute bacterial prostatitis will frequently experience a sudden onset of fever and chills. Clients diagnosed with chronic prostatitis have milder symptoms. 5. Pelvic pain is present in acute bacterial prostatitis. Pelvic pain may be present in chronic prostatitis, but the client will not appear acutely ill
The client diagnosed with diabetes insipidus weighed 180 pounds when the daily weight was taken yesterday. This morning's weight is 175.6 pounds. One liter of fluid weighs approximately 2.2 pounds. How much fluid, in milliliters, has the client lost?
2,000 mL has been lost. First, determine how many pounds the client has lost: 180 - 175.6 = 4.4 pounds lost Then, based on the fact that 1 liter of fluid weighs 2.2 pounds, determine how many liters of fluid have been lost: 4.4 ÷ 2.2 = 2 liters lost Then, because the question asks for the answer in milliliters, convert 2 liters into milliliters: 2 × 1,000 = 2,000 mL
The client diagnosed with cancer of the bladder is scheduled to have a cutaneous urinary diversion procedure. Which preoperative teaching intervention specific to the procedure should be included? 1. Demonstrate turn, cough, and deep breathing. 2. Explain a bag will drain the urine from now on. 3. Instruct the client on the use of a PCA pump. 4. Take the client to the ICU to become familiar with it.
2. A urinary diversion procedure involves the removal of the bladder. In a cutaneous procedure, the ureters are implanted in some way to allow for stoma formation on the abdominal wall, and the urine drains into a pouch. There are numerous methods used for creating the stoma.
The client diagnosed with renal calculi is admitted to the medical unit. Which intervention should the nurse implement first? 1. Monitor the client's urinary output. 2. Assess the client's pain and rule out complications. 3. Increase the client's oral fluid intake. 4. Use a safety gait belt when ambulating the client.
2. Assessment is the first part of the nursing process and is a priority. The renal colic pain can be so intense it can cause a vasovagal response, with resulting hypotension and syncope.
The client diagnosed with AKI is placed on bedrest. The client asks the nurse, "Why do I have to stay in bed? I don't feel bad." Which scientific rationale supports the nurse's response? 1. Bedrest helps increase the blood return to the renal circulation. 2. Bedrest reduces the metabolic rate during the acute stage. 3. Bedrest decreases the workload of the left side of the heart. 4. Bedrest aids in the reduction of peripheral and sacral edema.
2. Bedrest reduces exertion and the metabolic rate, thereby reducing catabolism and subsequent release of potassium and accumulation of endogenous waste products (urea and creatinine).
The nurse is caring for a client with a TURP. Which expected outcome indicates the client's condition is improving? 1. The client is using the maximum amount allowed by the PCA pump. 2. The client's bladder spasms are relieved by medication. 3. The client's scrotum is swollen and tender with movement. 4. The client has passed a large, hard, brown stool this morning.
2. Bladder spasms are common, but since the spasms are relieved with medication, this indicates the condition is improving.
The nurse is teaching the female client diagnosed with urinary tract tuberculosis (UTTB) before discharge. Which information should the nurse include specific to this diagnosis? 1. Instruct the client to take the medication with food. 2. Explain condoms should be used for intercourse during treatment. 3. Discuss the need for follow-up chest x-rays. 4. Encourage a well-balanced diet and fluid intake.
2. Clients diagnosed with tuberculosis of the renal tract should use condoms to prevent transmission of the mycobacterium. If the infection is located in the penis or urethra, abstaining from sexual activity is recommended.
The client is experiencing urinary incontinence. Which intervention should the nurse implement? 1. Teach the client to drink prune juice weekly. 2. Encourage the client to eat a high-fiber diet. 3. Discuss the need to urinate every 6 hours. 4. Explain the importance of wearing cotton underwear.
2. Clients experiencing incontinence should eat a high-fiber diet to avoid constipation, which increases pressure on the bladder, which may increase incontinence.
The client is 1 day postoperative TURP. Which task should the RN delegate to the UAP? 1. Increase the irrigation fluid to clear clots from the tubing. 2. Elevate the scrotum on a towel roll for support. 3. Change the dressing on the first postoperative day. 4. Teach the client how to care for the continuous irrigation catheter.
2. Elevating the scrotum on a towel for support is a task that can be delegated to the UAP.
The nurse is administering morning medications. Which medication should the nurse question administering? Client Name: ACCMR# 678905Diagnosis: Acute Renal Failure Age: 42 years Allergies: Penicillin Medication 0701-1900 1901-0700 Furosemide 80 mg PO daily 0900 K + 4.3 Erythropoietin Sub Q daily ×3 days 0900 Multivitamin with iron PO daily 0900 Levothyroxine 0.75 mcg PO daily 0900 1. Furosemide. 2. Erythropoietin. 3. Multivitamin with iron. 4. Levothyroxine.
2. Erythropoietin (Epogen) is frequently prescribed for the anemia associated with renal failure; however, this is an incomplete order because no dosage is prescribed. The nurse should contact the HCP to determine the dose to be administered. The dose is determined by units/kilogram/dose.
The nurse is caring for a client diagnosed with possible AKI. Which condition predisposes the client to develop prerenal AKI? 1. Diabetes mellitus. 2. Hypotension. 3. Aminoglycosides. 4. Benign prostatic hypertrophy.
2. Hypotension, which causes a decreased blood supply to the kidney, is one of the most common causes of prerenal AKI (before the kidney).
The nurse observes red urine and several large clots in the tubing of the normal saline continuous irrigation catheter for the client 1 day postoperative TURP. Which intervention should the nurse implement? 1. Remove the indwelling catheter. 2. Titrate the NS irrigation to run faster. 3. Administer protamine sulfate IVP. 4. Administer vitamin K slowly.
2. Increasing the irrigation fluid will flush out the clots and blood.
Which intervention is most important for the nurse to implement for the client diagnosed with possible renal calculi? 1. Assess the client's neurological status every 2 hours. 2. Strain all urine and send any sediment to the laboratory. 3. Monitor the client's creatinine and BUN levels. 4. Take a 24-hour dietary recall during the client interview.
2. Passing a renal stone may negate the need for the client to have lithotripsy or a surgical procedure. Therefore, all urine must be strained, and a stone, if found, should be sent to the laboratory to determine what caused the stone.
The male client diagnosed with metastatic cancer of the bladder is emaciated and refuses to eat. Which nursing action is an example of the ethical principle of paternalism? 1. The nurse allows the client to talk about not wanting to eat. 2. The nurse tells the client if he does not eat, a feeding tube will be placed. 3. The nurse consults the dietitian about the client's nutritional needs. 4. The nurse asks the family to bring favorite foods for the client to eat.
2. Paternalism is deciding for the client what is best, similar to a parent making decisions for a child. Feeding a client, as with a feeding tube, without the client wishing to eat is paternalism.
The male client diagnosed with CKD secondary to diabetes has been receiving dialysis for 12 years. The client is notified he will not be placed on the kidney transplant list. The client tells the nurse he will not be back for any more dialysis treatments. Which response by the nurse is most therapeutic? 1. "You cannot just quit your dialysis. This is not an option." 2. "You're angry at not being on the list, and you want to quit dialysis?" 3. "I will call your nephrologist right now so you can talk to the HCP." 4. "Make your funeral arrangements because you are going to die."
2. Reflecting the client's feelings and restating them are therapeutic responses the nurse should use when addressing the client's issues.
The clinic nurse is caring for a client diagnosed with chronic pyelonephritis and prescribed trimethoprim-sulfamethoxazole twice a day for 90 days. Which statement is the scientific rationale for prescribing this medication? 1. The antibiotic will treat the bladder spasms that accompany a UTI. 2. If the urine cannot be made bacteria-free, the medication will suppress bacterial growth. 3. In 3 months, the client should be rid of all bacteria in the urinary tract. 4. The HCP is providing the client with enough medication to treat future infections.
2. Some clients develop a chronic infection and must receive antibiotic therapy as a routine daily medication to suppress bacterial growth. The prescription for trimethoprim-sulfamethoxazole (Bactrim), a sulfa antibiotic, will be refilled after the 90 days and continued.
The client has received IV solutions for 3 days through a 20-gauge IV catheter placed in the left cephalic vein. On morning rounds, the nurse notes the IV site is tender to palpation, and a red streak has formed. Which intervention should the nurse implement first? 1. Start a new IV in the right hand. 2. Discontinue the intravenous line. 3. Complete an incident record. 4. Place a warm washrag over the site.
2. The client has clinical manifestations of phlebitis, and the IV must be removed to prevent further complications.
The nurse is preparing the discharge teaching plan for the male client with a left-sided nephrectomy. Which statement indicates the teaching is effective? 1. "I can't wait to start back to work next week; I really need the money." 2. "I will take my temperature, and if it is above 100.5°F, I will call my doctor." 3. "I am glad I won't have to keep track of how much I urinate in the day." 4. "I am happy I will be able eat what I usually eat; I don't like this food."
2. The client or family needs to contact the surgeon if the client develops chills, flank pain, decreased urinary output, or fever
The nurse in the dialysis center is initiating the morning dialysis run. Which client should the nurse assess first? 1. The client with hemoglobin of 9.8 g/dL and hematocrit of 30%. 2. The client with no palpable thrill or auscultated bruit. 3. The client reporting being exhausted and is sleeping. 4. The client prescribed antihypertensive medication.
2. The client's dialysis access is compromised, so this client should be assessed first.
The RN is discussing how to prioritize care with the UAP. Which client should the RN instruct the UAP to see first? 1. The immobile client needing sequential compression devices removed. 2. The older woman requiring assistance ambulating to the bathroom. 3. The surgical client needing help changing the gown after bathing. 4. The male client requiring the intravenous catheter be discontinued.
2. The older woman may have age-related changes (decreased bladder capacity, weakened urinary sphincter, shortened urethra) causing urinary urgency or incontinence. The older client is at risk for falling while attempting to get to the bathroom, so this client should be seen first.
Which clinical manifestations should the nurse expect to assess for the client diagnosed with a ureteral renal stone? 1. Dull, aching flank pain, and microscopic hematuria. 2. Nausea; vomiting; pallor; and cool, clammy skin. 3. Gross hematuria and dull suprapubic pain with voiding. 4. The client will be asymptomatic.
2. The severe flank pain associated with a stone in the ureter often causes a sympathetic response with associated nausea; vomiting; pallor; and cool, clammy skin.
The client post-thyroidectomy reports numbness and tingling around the mouth and the tips of the fingers. Which intervention should the nurse implement first? 1. Notify the health-care provider immediately. 2. Tap the cheek about 2 cm anterior to the earlobe. 3. Check the serum calcium and magnesium levels. 4. Prepare to administer calcium gluconate IVP.
2. These are clinical manifestations of hypocalcemia, and the nurse can confirm this by tapping the cheek to elicit the Chvostek's sign. If the muscles of the cheek begin to twitch, then the HCP should be immediately notified because hypocalcemia is a medical emergency.
The UAP tells the nurse the client diagnosed with CKD has a white crystal-like layer on top of the skin. Which intervention should the RN implement? 1. Have the assistant apply a moisture barrier cream to the skin. 2. Instruct the UAP to bathe the client in cool water. 3. Tell the UAP not to turn the client in this condition. 4. Explain this is normal and do not do anything for the client.
2. These crystals are uremic frost resulting from irritating toxins deposited in the client's tissues. Bathing in cool water will remove the crystals, promote client comfort, and decrease the itching resulting from uremic frost
The nurse is caring for an older client with an indwelling catheter. Which data warrant further investigation? 1. The client's temperature is 98°F. 2. The client has become confused and irritable. 3. The client's urine is clear and light yellow. 4. The client feels the need to urinate.
2. When an older client's mental status changes to confused and irritable, the nurse should seek the etiology, which may be a UTI secondary to an indwelling catheter. Older clients often do not present with classic clinical manifestations of infection.
The nurse is preparing a teaching care plan for the client diagnosed with nephrotic syndrome. Which intervention should the nurse include? 1. Stop steroids if a moon face develops. 2. Provide teaching for taking diuretics. 3. Increase the intake of dietary sodium. 4. Report a decrease in daily weight.
2. Treatment includes diuretics to eliminate dependent edema, usually in the ankles and sacrum. Medication teaching is an appropriate intervention.
The nurse is preparing a plan of care for the client diagnosed with acute glomerulonephritis. Which statement is an appropriate long-term goal? 1. The client will have a blood pressure within normal limits. 2. The client will show no protein in the urine. 3. The client will maintain normal renal function. 4. The client will have clear lung sounds.
3. A long-term complication of glomerulonephritis is that it can become chronic if unresponsive to treatment, and this can lead to end-stage renal disease. Maintaining renal function is an appropriate long-term goal.
The client with a history of renal calculi calls the clinic and reports having burning on urination, chills, and an elevated temperature. Which instruction should the nurse discuss with the client? 1. Increase water intake for the next 24 hours. 2. Take two acetaminophen to help decrease the temperature. 3. Come to the clinic and provide a urine specimen for urinalysis. 4. Use a sterile 4 × 4 gauze to strain the client's urine.
3. A urinalysis can assess for hematuria, the presence of WBCs, crystal fragments, or all three, which can determine if the client has a urinary tract infection or possibly a renal stone, with accompanying clinical manifestations of UTI.
The nurse is developing a plan of care for a client diagnosed with AKI. Which statement is an appropriate outcome for the client? 1. Monitor intake and output every shift. 2. Decrease of pain by three levels on a 1-to-10 scale. 3. Electrolytes are within normal limits. 4. Administer enemas to decrease hyperkalemia.
3. AKI causes an imbalance of electrolytes (potassium, sodium, calcium, phosphorus). Therefore, the desired client outcome is electrolytes within normal limits.
The male client diagnosed with CKD received the initial dose of erythropoietin 1 week ago. Which report by the client indicates the need to notify the health-care provider (HCP)? 1. The client reports flu-like symptoms. 2. The client reports being tired all the time. 3. The client reports an elevation in his blood pressure. 4. The client reports discomfort in his legs and back.
3. After the initial administration of erythropoietin, a client's antihypertensive medications may need to be adjusted. Therefore, this report requires notification of the HCP. Erythropoietin therapy is contraindicated in clients diagnosed with uncontrolled hypertension
The client diagnosed with AKI is admitted to the intensive care unit and placed on a therapeutic diet. Which diet is most appropriate for the client? 1. A high-potassium and low-calcium diet. 2. A low-fat and low-cholesterol diet. 3. A high-carbohydrate and restricted-protein diet. 4. A regular diet with six small feedings a day.
3. Carbohydrates are increased to provide for the client's caloric intake, and protein is restricted to minimize protein breakdown and to prevent the accumulation of toxic waste products.
Which modifiable risk factor should the nurse identify for the development of cancer of the bladder in a client? 1. Previous exposure to chemicals. 2. Pelvic radiation therapy. 3. Cigarette smoking. 4. Parasitic infections of the bladder.
3. Cigarette smoke contains more than 400 chemicals, 17 of which are known to cause cancer. The risk is directly proportional to the amount of smoking.
The client has been vomiting and has had numerous episodes of diarrhea. Which laboratory test should the nurse monitor? 1. Serum calcium. 2. Serum phosphorus. 3. Serum potassium. 4. Serum sodium.
3. Clients lose potassium from the GI tract or through the use of diuretic medications. Potassium imbalances can lead to cardiac arrhythmias.
The client, after undergoing an exploratory laparotomy with subsequent removal of a large intestinal tumor, has a nasogastric tube (NGT) in place and an IV running at 150 mL/hr via an IV pump. Which data should be reported to the HCP? 1. The pump keeps sounding an alarm indicating the high pressure has been reached. 2. Intake is 1,800 mL, NGT output is 550 mL, and Foley output is 950 mL. 3. On auscultation, crackles and rhonchi in all lung fields are noted. 4. The client has negative pedal edema and an increasing level of consciousness.
3. Crackles and rhonchi in all lung fields indicate the body is not able to process the amount of fluid being infused. This should be brought to the HCP's attention.
The client is admitted to a nursing unit from a long-term care facility with the laboratory results populated in the chart below. Which condition is a cause for these findings? Hematocrit (Hct) 56 Male: 42%-52% Female: 36%-48% Sodium (Na1) 152 135-145 mEq/L or mmol/L Potassium (K) 5.5 3.5-5.3 MEq/L or mmol/L 1. Overhydration. 2. Anemia. 3. Dehydration. 4. Acute kidney injury.
3. Dehydration results in concentrated serum, causing laboratory values to increase because the blood has normal constituents but not enough volume to dilute the values to within normal range or possibly lower.
The laboratory data reveal a calcium phosphate renal stone for a client diagnosed with renal calculi. Which discharge teaching intervention should the nurse implement? 1. Encourage the client to eat a low-purine diet and limit foods such as organ meats. 2. Explain the importance of not drinking water 2 hours before bedtime. 3. Discuss the importance of limiting vitamin D-enriched foods. 4. Prepare the client for extracorporeal shock wave lithotripsy (ESWL).
3. Dietary changes for preventing renal stones include reducing the intake of the primary substance forming the calculi. In this case, limiting vitamin D will inhibit the absorption of calcium from the gastrointestinal tract.
The elderly client is diagnosed with chronic glomerulonephritis. Which laboratory value indicates to the nurse the condition has become worse? BUN 15 8-21 mg/dL Age ≥ 90 years: 10-31 mg/dL Creatinine 1.2 Male: 0.61-1.21 mg/dL Female: 0.51-1.11 mg/dL Glomerular filtration rate (GFR) 40 Over 60 mL/min/1.73 m2 Creatinine clearance (24 hr urine) 100 Male: 85-125 mL/min/1.73 m2 Female: 75-115 mL/min/1.73 m2 1. The blood urea nitrogen. 2. The creatinine level. 3. The glomerular filtration rate. 4. The 24-hour creatinine clearance.
3. Glomerular filtration rate (GFR) in a normally functioning kidney is over 60 mL/min/1.73 m2. If the GFR is decreased below 60 mL/min, it may indicate kidney disease. A GFR of 15 or lower may mean kidney failure
The client diagnosed with AKI is experiencing hyperkalemia. Which medication should the nurse prepare to administer to help decrease the potassium level? 1. Erythropoietin. 2. Calcium gluconate. 3. Regular insulin. 4. Osmotic diuretic.
3. Regular insulin, along with glucose, will drive potassium into the cells, thereby lowering serum potassium levels temporarily.
The nurse and a UAP are caring for a group of clients. Which nursing intervention should the RN perform? 1. Measure the client's output from the indwelling catheter. 2. Record the client's intake and output on the I&O sheet. 3. Instruct the client on appropriate fluid restrictions. 4. Provide water for a client diagnosed with diabetes insipidus.
3. The RN cannot delegate teaching.
The client diagnosed with renal calculi is scheduled for lithotripsy. Which postprocedure nursing task is the most appropriate to delegate to the UAP? 1. Monitor the amount, color, and consistency of urine output. 2. Teach the client about the care of the indwelling Foley catheter. 3. Assist the client to the car when being discharged home. 4. Take the client's postprocedural vital signs.
3. The UAP could assist the client to the car once the discharge has been completed.
The nurse is caring for a client diagnosed with possible nephrotic syndrome. Which intervention should be included in the plan of care? 1. Monitor the urine for bright-red bleeding. 2. Evaluate the calorie count of the 500-mg protein diet. 3. Assess the client's sacrum for dependent edema. 4. Monitor for a high serum albumin level.
3. The classic clinical manifestation of nephrotic syndrome is dependent edema located on the client's sacrum and ankles.
Which outcome should the nurse identify for the client diagnosed with fluid volume excess? 1. The client will void a minimum of 30 mL per hour. 2. The client will have elastic skin turgor. 3. The client will have no adventitious breath sounds. 4. The client will have a serum creatinine of 1.4 mg/dL.
3. The client diagnosed with FVE has too much fluid. Excess fluid is reflected by adventitious breath sounds. Therefore, an expected outcome is to have no excess fluid, as evidenced by normal, clear breath sounds.
The nurse has identified the concept of urinary elimination for a client. Which information is most important for the nurse to provide to the HCP the next day? Intake and Output Day 1 (Shift Time)Oral (mL)Intravenous (mL)Urine (mL)Nasogastric Tube (mL)Other (Specify) (mL) 0701-1900 2,200 1,600 735 Emesis 40 1901-0700 1,600 1,400 575 Total 3,800 3,000 1,310 40 1. The client vomited 40 mL on the day shift. 2. The client has adequate oral intake, and IV fluids are not needed. 3. The client has had 6,800 mL intake and 1,350 mL output in the last 24 hours. 4. The client does not like to have to keep the urine for measurement.
3. The client has a deficit output of almost 5,500 mL. This should be brought to the HCP's attention to determine if renal insufficiency is present.
The nurse is discharging a client diagnosed with a catheter-associated urinary tract infection (CAUTI). Which information should the nurse include in the discharge teaching? 1. Limit fluid intake so the urinary tract can heal. 2. Collect a routine urine specimen for culture. 3. Take all the antibiotics as prescribed. 4. Tell the client to void every 5 to 6 hours.
3. The client should be taught to take all the prescribed medication anytime a prescription is written for antibiotics.
The client receiving hemodialysis is being discharged home from the dialysis center. Which instruction should the nurse teach the client? 1. Notify the HCP if oral temperature is 102°F or greater. 2. Apply ice to the access site if it starts bleeding at home. 3. Maintain fluid and salt restrictions to decrease side effects. 4. Encourage the significant other to make decisions for the client.
3. The client should maintain fluid and salt restrictions to avoid side effects related to excess salt and fluid accumulation between dialysis treatments
The RN is observing the UAP providing direct care to a client with an indwelling catheter. Which data warrant immediate intervention by the nurse? 1. The UAP secures the tubing to the client's leg with tape. 2. The UAP provides catheter care with the client's bath. 3. The UAP puts the collection bag on the client's bed. 4. The UAP cares for the catheter after thorough hand washing.
3. The drainage bag should be kept below the level of the bladder to prevent the reflux of urine into the renal system; it should not be placed on the bed.
The nurse is caring for a client diagnosed with diabetic ketoacidosis (DKA). Which statement best explains the scientific rationale for the client's Kussmaul's respirations? 1. The kidneys produce excess urine and the lungs try to compensate. 2. The respirations increase the amount of carbon dioxide in the bloodstream. 3. The lungs speed up to release carbon dioxide and increase the pH. 4. The shallow and slow respirations will increase the HCO3 in the serum.
3. The lungs attempt to increase the blood pH level by blowing off the carbon dioxide (carbonic acid).
The nurse is discussing kidney transplants with clients at a dialysis center. Which type of donation is most common? 1. Living, related donor. 2. Nondirected, altruistic donor. 3. Cadaver donor. 4. Xenotransplantation donor.
3. The most common form of kidney donation is cadaveric or from a deceased donor.
Which nursing intervention is most important before attempting to catheterize a client? 1. Determine the client's history of catheter use. 2. Evaluate the level of anxiety of the client. 3. Verify the client is not allergic to latex. 4. Assess the client's sensation level and ability to void.
3. The nurse should always assess for allergies to latex before inserting a latex catheter or using a drainage system because, if the client is allergic to latex, use of it could cause a life-threatening reaction.
Which intervention should the RN implement first for the client having incontinence? 1. Palpate the client's bladder to assess for urinary retention. 2. Obtain a bedside commode for the client. 3. Assist the client with changing the wet clothes. 4. Request the UAP to change the client's linens.
3. The nurse should first assist the client in getting out of the wet clothes before any other action. Wet clothes are embarrassing to the client and can lead to skin breakdown.
The telemetry nurse is reviewing the laboratory results for a client. Which further assessment data should the nurse determine before notifying the HCP? Laboratory TestClient ValuesNormal Values Potassium 2.3 3.5-5.3 mEq/L Sodium 139 135-145 mEq/L Glucose 143 Fasting < 100 mg/dL Random < 200 mg/Dl Creatinine 1.5 M: 0.61-1.21 mg/dL F: 0.51-1.11 mg/dL BUN 20 8 to 21 mg/dL Age ≥ 90 years: 10 to 31 mg/dL B-Type Natriuretic Peptide (BNP) 80 Less than 125 pg/mL 1. Obtain the client's 24-hour urine output. 2. Ask the UAP to get a blood glucose reading. 3. Assess the client's telemetry reading. 4. Call the rapid response team (RRT).
3. The potassium level is at a critical level. Low potassium levels impact the cardiac rhythm by causing a dysrhythmia. The nurse should assess the telemetry reading to determine if this is occurring.
The nurse is monitoring the client's laboratory values. Which laboratory report is diagnostic for a UTI? 1. Complete Blood Count Date: Today Laboratory TestClient ValueNormal Values Red Blood Cells (RBCs) 3.8 Male: 4.21-5.81 (106 cells/microL) Female: 3.61-5.11 (106 cells/microL) Hemoglobin (Hgb) 11 Male: 14-17.3 g/dL Female: 11.7-15.5 g/dL Hematocrit (Hct) 33% Male: 42%-52% Female: 36%-48% Platelet 250 140-400 × (103/microL) White Blood Cells (WBCs) 12.5 4.5-11.1 × (103/cells/microL) 2. Urinalysis Client Values Normal Values pH 5.5 4.5-8 Color Dark amber Amber yellow Clarity Cloudy Clear Specific gravity 1.029 1.005-1.03 Osmolality 450 50-1200 mOsm/kg (random) Protein 0 Less than 20 mg/dL Glucose 0 None Ketones 0 None RBC 0 Less than 5/hpf WBC 4 Less than 5/hpf 3. Urine Culture Urine CultureOrganismSensitivity 48-hour result Greater than 105 Escherichia coli bacteria Ceftriaxone Cefazolin Imipenem-Cilastatin 4. Metanephrines Client Value Normal Values Metanephrines, total (24-hour urine) 700 94-832 mcg/24 hr
3. The urine culture has identified an infectious organism. This is the diagnostic test for a UTI.
The nurse is examining a 15-year-old female client reporting pain, frequency, and urgency when urinating. After asking the parent to leave the room, which question should the nurse ask the client? 1. "When was your last menstrual cycle?" 2. "Have you noticed any change in the color of the urine?" 3. "Are you sexually active?" 4. "What have you taken for the pain?"
3. These are clinical manifestations of cystitis, a bladder infection, which may be caused by sexual intercourse as a result of the introduction of bacteria into the urethra during the physical act. A teenager may not want to divulge this information in front of the parent.
The client diagnosed with cancer of the bladder states, "I have young children. I am too young to die." Which statement is the nurse's best response? 1. "This cancer is treatable, and you should not give up." 2. "Cancer occurs at any age. It is just one of those things." 3. "You are afraid of dying and what will happen to your children." 4. "Have you talked to your children about your death?"
3. This is an example of restating, a therapeutic technique used to clarify the client's feelings and encourage a discussion of those feelings.
The nurse is caring for the client diagnosed with chronic kidney disease (CKD) experiencing metabolic acidosis. Which statement best describes the scientific rationale for metabolic acidosis in this client? 1. There is an increased excretion of phosphates and organic acids, which leads to an increase in arterial blood pH. 2. A shortened life span of red blood cells because of damage secondary to dialysis treatments in turn leads to metabolic acidosis. 3. The kidney cannot excrete increased levels of acid because it cannot excrete ammonia or cannot reabsorb sodium bicarbonate. 4. An increase in nausea and vomiting causes a loss of hydrochloric acid and the respiratory system cannot compensate adequately.
3. This is the correct scientific rationale for metabolic acidosis occurring in the client diagnosed with CKD.
The client, postoperative TURP, asks the nurse, "When will I know if I will be able to have sex after my TURP?" Which response is most appropriate by the nurse? 1. "You seem anxious about your surgery." 2. "Tell me about your fears of impotency." 3. "Potency can return in 6 to 8 weeks." 4. "Did you ask your doctor about your concern?"
3. Usually, this is the length of time clients need to wait before having sexual intercourse; this is the information the client wants to know.
The client is diagnosed with a uric acid stone. Which foods should the client eliminate from the diet to help prevent reoccurrence? 1. Beer and colas. 2. Asparagus and cabbage. 3. Venison and sardines. 4. Cheese and eggs.
3. Venison, sardines, goose, organ meats, and herring are high-purine foods, which should be eliminated from the diet to help prevent uric acid stones.
The nurse is caring for clients in a renal surgery unit. After the afternoon report, which client should the nurse assess first? 1. The male client just returned from a CT scan stating he left his glasses in the x-ray department. 2. The client 1 day postoperative with a moderate amount of serous drainage on the dressing. 3. The client scheduled for surgery in the morning and wants an explanation of the operative procedure before signing the permit. 4. The client, after ileal conduit surgery this morning, has not had any drainage in the drainage bag.
4. An ileal conduit is a procedure diverting urine from the bladder and provides an alternate cutaneous pathway for urine to exit the body. Urinary output should always be at least 30 mL/hr. This client should be assessed to make sure the stents placed in the ureters have not become dislodged or blocked.
The client diagnosed with CKD is receiving peritoneal dialysis. Which assessment data warrant immediate intervention by the nurse? 1. Inability to auscultate a bruit over the fistula. 2. The client's abdomen is soft, is nontender, and has bowel sounds. 3. The dialysate being removed from the client's abdomen is clear. 4. The dialysate instilled was 1,500 mL and removed was 1,500 mL.
4. Because the client is in ESRD, fluid must be removed from the body, so the output should be more than the amount instilled. These assessment data require intervention by the nurse.
The client is admitted with a serum sodium level of 110 mEq/L. Which nursing intervention should be implemented? 1. Encourage fluids orally. 2. Administer 10% saline solution IVPB. 3. Administer antidiuretic hormone intranasally. 4. Place on seizure precautions.
4. Clients with sodium levels less than 120 mEq/L are at risk for seizures as a complication. The lower the sodium level, the greater the risk of a seizure.
The female client in an outpatient clinic is being sent home with a diagnosis of UTI. Which instruction should the nurse teach to prevent a recurrence of a UTI? 1. Clean the perineum from back to front after a bowel movement. 2. Take warm tub baths instead of hot showers daily. 3. Void immediately preceding sexual intercourse. 4. Avoid coffee, tea, colas, and alcoholic beverages.
4. Coffee, tea, cola, and alcoholic beverages are urinary tract irritants.
The nurse is developing a nursing care plan for the client diagnosed with CKD. Which nursing problem is a priority for the client? 1. Low self-esteem. 2. Knowledge deficit. 3. Activity intolerance. 4. Excess fluid volume.
4. Excess fluid volume is the priority because of the stress placed on the heart and vessels, which could lead to heart failure, pulmonary edema, and death.
The RN and a licensed practical nurse (LPN) are caring for a group of clients. Which intervention should be assigned to the LPN? 1. Assessment of the client after a Kock pouch procedure. 2. Monitoring of the postoperative client with a WBC of 22 × 103/microL. 3. Administration of the prescribed antineoplastic medications. 4. Care for the client going for an MRI of the kidneys.
4. It is in the scope of practice for the LPN to care for this client.
The client is in the intensive care unit (ICU) after a motor vehicle accident in which the client lost an estimated 3 units of blood. Which action by the nurse could prevent the client from developing AKI? 1. Take and document the client's vital signs every hour. 2. Assess the client's dressings every 2 hours. 3. Check the client's urinary output every shift. 4. Maintain the client's blood pressure greater than 100/60.
4. Maintaining the client's blood pressure to greater than 100/60 ensures perfusion of the kidneys. AKI occurs when the kidneys have not been adequately perfused. Vasopressor drips are used to maintain BP.
The nurse is admitting a client diagnosed with acute kidney injury (AKI). Which question is most important for the nurse to ask during the admission interview? 1. "Have you recently traveled outside the United States?" 2. "Did you recently begin a vigorous exercise program?" 3. "Is there a chance you have been exposed to a virus?" 4. "What over-the-counter medications do you take regularly?"
4. Medications such as NSAIDs and some herbal remedies are nephrotoxic; therefore, asking about medications is appropriate
The client diagnosed with possible renal calculi is scheduled for a renal ultrasound. Which intervention should the nurse implement for this procedure? 1. Ask if the client is allergic to shellfish or iodine. 2. Keep the client NPO 8 hours before the ultrasound. 3. Ensure the client has a signed informed consent form. 4. Explain the test is noninvasive, and there is no discomfort.
4. No special preparation is needed for this noninvasive, nonpainful test. A conductive gel is applied to the back or flank and then a transducer is applied, which produces sound waves, resulting in a picture.
The nurse caring for a client diagnosed with CKD writes a client problem of "noncompliance with dietary restrictions." Which intervention should be included in the plan of care? 1. Teach the client the proper diet to eat while undergoing dialysis. 2. Refer the client and significant other to the dietitian. 3. Explain the importance of eating the proper foods. 4. Determine the reason for the client not adhering to the diet.
4. Noncompliance is a choice the client has a right to make, but the nurse should determine the reason for the noncompliance and then take appropriate actions based on the client's rationale. For example, if the client has financial difficulties, the nurse may suggest how the client can afford the proper foods along with medications, or the nurse may be able to refer the client to a social worker.
The client diagnosed with AKI has a serum potassium level of 6.8 mEq/L. Which collaborative treatment should the nurse anticipate for the client? 1. Administer a phosphate binder. 2. Type and crossmatch for whole blood. 3. Assess the client for leg cramps. 4. Prepare the client for dialysis.
4. Normal potassium level is 3.5 to 5.3 mEq/L. A level of 6.8 mEq/L is life-threatening and could lead to cardiac dysrhythmias. Therefore, the client may be dialyzed to decrease the potassium level quickly. This requires an HCP order, so it is a collaborative intervention.
The client is diagnosed with an acute episode of ureteral calculi. Which client problem is the priority when caring for this client? 1. Fluid volume loss. 2. Knowledge deficit. 3. Impaired urinary elimination. 4. Alteration in comfort.
4. Pain is the priority. The pain can be so severe a sympathetic response may occur, causing nausea; vomiting; pallor; and cool, clammy skin.
The nurse is assessing a client diagnosed with urethral strictures. Which data support the diagnosis? 1. Reports of frequency and urgency. 2. Clear yellow drainage from the urethra. 3. Reports of burning during urination. 4. A diminished force and stream during voiding.
4. The client diagnosed with urethral strictures will report a decrease in force and stream during voiding. The stricture is treated by dilation using small filiform bougies.
The client is 2 days post-ureterosigmoidostomy for cancer of the bladder. Which assessment data warrants notification of the HCP by the nurse? 1. The client reports pain at a "3," 30 minutes after being medicated. 2. The client reports it hurts to cough and deep breathe. 3. The client ambulates to the end of the hall and back before lunch. 4. The client is lying in a fetal position and has a rigid abdomen.
4. The client is drawn up in a position that relieves pressure off the abdomen; a rigid abdomen is an indicator of peritonitis, a medical emergency.
The client is 12 hours postoperative renal surgery. Which data warrant immediate intervention by the nurse? 1. The abdomen is soft, nontender, and rounded. 2. Pain is not felt with dorsal flexion of the foot. 3. The urine output is 60 mL for the past 2 hours. 4. The client's trough vancomycin level is 24 mcg/mL.
4. The client with restricted kidney function after surgery should be monitored for damage as a result of the use of aminoglycoside antibiotics, such as vancomycin, which are nephrotoxic. This level is high and warrants notifying the HCP.
Which intervention should the nurse implement when caring for the client with a nephrostomy tube? 1. Change the dressing only if soiled by urine. 2. Clean the end of the connecting tubing with povidone-iodine. 3. Clean the drainage system every day with bleach and water. 4. Assess the tube for kinks to prevent obstruction.
4. The nephrostomy tube should never be clamped or have kinks because an obstruction can cause pyelonephritis.
The client with a TURP and continuous irrigation catheter reports the need to urinate. Which intervention should the nurse implement first? 1. Call the surgeon to inform the HCP of the client's report. 2. Administer the client a narcotic medication for pain. 3. Explain to the client this sensation happens frequently. 4. Assess the continuous irrigation catheter for patency.
4. The nurse should always assess any report before dismissing it as a commonly occurring problem.
The older client recovering from a prostatectomy has been experiencing stress incontinence. Which independent nursing intervention should the nurse discuss with the client? 1. Establish a set voiding frequency of every 2 hours while awake. 2. Encourage a family member to assist the client to the bathroom to void. 3. Apply a transurethral electrical stimulator to relieve symptoms of urinary urgency. 4. Discuss the use of a "bladder drill," including a timed voiding schedule.
4. The use of the bladder-training drill is helpful in stress incontinence. The client is instructed to void at scheduled intervals. After consistently being dry, the interval is increased by 15 minutes until the client reaches an acceptable interval.
The client had surgery to remove a kidney stone. Which laboratory assessment data warrant immediate intervention by the nurse? 1. A serum potassium level of 3.8 mEq/L. 2. A urinalysis shows microscopic hematuria. 3. A creatinine level of 0.8 mg/dL. 4. A white blood cell count of 14 × 103/microL.
4. The white blood cell count is elevated; normal is 4.5 to 11.1 × 103/microL.
Which nursing diagnosis is a priority for the client after a TURP? 1. Potential for sexual dysfunction. 2. Potential for an altered body image. 3. Potential for chronic infection. 4. Potential for hemorrhage.
4. This is a potentially life-threatening problem.
The client from a long-term care facility is admitted to the medical unit with a fever, hot flushed skin, and clumps of white sediment in the indwelling catheter. Which intervention should the nurse implement first? 1. Start an IV with a 20-gauge catheter. 2. Initiate antibiotic therapy IVPB. 3. Collect a urine specimen for culture. 4. Change the indwelling catheter.
4. Unless the nurse can determine the catheter has been inserted within a few days, the nurse should replace the catheter and then get a specimen. This will provide the most accurate specimen for analysis.
The nurse performs bladder irrigation through an indwelling catheter. The nurse instilled 90 mL of sterile normal saline. The catheter drained 710 mL. What is the client's output?
620 mL of urine. The amount of sterile normal saline is subtracted from the total volume removed from the catheter. 710 - 90 = 620.
The client diagnosed with CKD is placed on a fluid restriction of 1,500 mL/day. On the 7 a.m. to 7 p.m. shift, the client drank an 8-ounce cup of coffee, 4 ounces of juice, 12 ounces of tea, and 2 ounces of water with medications. What amount of fluid can the 7 p.m. to 7 a.m. nurse give to the client?
720 mL. The nurse must add up how many milliliters of fluid the client drank during the 7 a.m. to 7 p.m. shift and then subtract that number from 1,500 mL to determine how much fluid the client can receive on the 7 p.m. to 7 a.m. shift. One ounce is equal to 30 mL. The client drank 26 ounces (8 + 4 + 12 + 2) of fluid, or 780 mL (26 × 30) of fluid. Therefore, the client can have 720 mL (1,500 - 780) of fluid during the 7 p.m. to 7 a.m. shift.
The nurse emptied 2,000 mL from the drainage bag of a client's continuous irrigation after transurethral resection of the prostate (TURP). The amount of irrigation in the bag hanging was 3,000 mL at the beginning of the shift. There were 1,800 mL left in the bag 8 hours later. What is the correct urine output at the end of the 8 hours?
800 mL. First, determine the amount of irrigation fluid: 3,000 - 1,800 = 1,200 mL of irrigation fluid Then, subtract 1,200 mL of irrigation fluid from the drainage of 2,000 mL to determine the urine output: 2,000 - 1,200 = 800 mL of urine output
