Master quizlet for nur 114 exam 2 questions (Colon cancer/Elimination/Inflammation)
An 18 y.o. student is admitted with dark urine, fever, and flank pain and is diagnosed with acute glomerulonephritis. Which would most likely be in this student's health history? A. Renal calculi B. Renal trauma C. Recent sore throat D. Family history of acute glomerulonephritis
Answer: C The most common form of acute glomerulonephritis is caused by group A beta-hemolytic streptococcal infection elsewhere in the body
The nurse is preparing to care for the client following a renal scan. Which of the following would the nurse include in the plan of care? A. Place the client on radiation precautions for 18 hours B. Save all urine in a radiation safe container for 18 hours C. Limit contact with the client to 20 minutes per hour D . No special precautions except to wear gloves if in contact with the client's urine
Answer: D No specific precautions are necessary following a renal scan. Urination into a commode is acceptable without risk from the small amount of radioactive material to be excreted. The nurse wears gloves to maintain body secretion precautions.
A client is complaining of severe flank and abdominal pain. A flat plate of the abdomen shows urolithiasis. Which of the following interventions is important? a. Strain all urine b. Limit fluid intake c. Enforce strict bed rest d. Encourage a high calcium diet
Answer: A. Urine should be strained for calculi and sent to the lab for analysis. Fluid intake of 3 to 4 L is encouraged to flush the urinary tract and prevent further calculi formation. A low-calcium diet is recommended to help prevent the formation of calcium calculi. Ambulation is encouraged to help pass the calculi through gravity.
Because a client's renal stone was found to be composed to uric acid, a low-purine, alkaline-ash diet was ordered. Incorporation of which of the following food items into the home diet would indicate that the client understands the necessary diet modifications? A. Milk, apples, tomatoes, and corn B. Eggs, spinach, dried peas, and gravy C. Salmon, chicken, caviar, and asparagus D. Grapes, corn, cereals, and liver
Answer: A Because a high-purine diet contributes to the formation of uric acid, a low-purine diet is advocated. An alkaline-ash diet is also advocated, because uric acid crystals are more likely to develop in acid urine. Foods that may be eaten as desired in a low-purine diet include milk, all fruits, tomatoes, cereals, and corn. Food allowed on an alkaline-ash diet include milk, fruits (except cranberries, plums, and prunes), and vegetables (especially legumes and green vegetables). Gravy, chicken, and liver are high in purine.
A male client is recovering from an ileostomy that was performed to treat inflammatory bowel disease. During discharge teaching, the nurse should stress the importance of: A. increasing fluid intake to prevent dehydration B. wearing an appliance pouch only at bedtime C. consuming a low-protein, high-fiber diet D. taking only enteric-coated medications
Answer: A Because stool forms in the large intestine, an ileostomy typically drains liquid waste. To avoid fluid loss through ileostomy drainage, the nurse should instruct the client to increase fluid intake. The nurse should teach the client to wear a collection appliance at all times because ileostomy drainage is incontinent, to avoid high-fiber foods because they may irritate the intestines, and to avoid enteric-coated medications because the body can't absorb them after an ileostomy
You have a paraplegic patient with renal calculi. Which factor contributes to the development of calculi? A. Increased calcium loss from the bones B. Decreased kidney function C. Decreased calcium intake D. High fluid intake
Answer: A Bones lose calcium when a patient can no longer bear weight. The calcium lost from bones form calculi, a concentration of mineral salts also known as a stone, in the renal system.
A priority nursing diagnosis for the client who is being discharged t home 3 days after a TURP would be: A. Deficient fluid volume B. Imbalanced Nutrition: Less than Body Requirements C. Impaired Tissue Integrity D. Ineffective Airway Clearance
Answer: A Deficient Fluid Volume is a priority diagnosis, because the client needs to drink a large amount of fluid to keep the urine clear. The urine should be almost without color. About 2 weeks after a TURP, when desiccated tissue is sloughed out, a secondary hemorrhage could occur. The client should be instructed to call the surgeon or go to the ED if at any time the urine turns bright red. The client is not specifically at risk for nutritional problems after a TURP. The client is not specifically at risk for nutritional problems after a TURP. The client is not specifically at risk for impaired tissue integrity because there is no external incision, and the client is not specifically at risk for airway problems because the procedure is done after spinal anesthesia.
A nurse has provided instructions to a female client with cystitis about measures to prevent recurrence. The nurse determines that the client needs further instruction if the client verbalizes to: a) take bubble baths for more effective hygiene b) wear underwater made of cotton or with cotton panels c) drink a glass of water and void after intercourse d) avoid wearing pantyhose while wearing socks
Answer: A Measures to prevent cystitis include increasing fluid intake to 3 L per day; consuming an acid-ash diet; wiping front to back after urination; using showers instead of tub baths; drinking water and voiding after intercourse; avoiding bubble baths, feminine hygiene sprays, or perfumed toilet tissue or sanitary pads; and wearing clothes that "breathe" (cotton pants, no tight jeans, no pantyhose under slacks). Other measures include teaching pregnant women to void every 2 hours, and teaching menopausal women to use estrogen vaginal creams to restore vaginal pH.
Which drug is indicated for pain related to acute renal calculi? A Narcotic analgesics B Nonsteroidal anti-inflammatory drugs (NSAIDS) C Muscle relaxants D Salicylates
Answer: A Narcotic analgesics are usually needed to relieve the severe pain of renal calculi. Muscle relaxants are typically used to treat skeletal muscle spasms. NSAIDS and salicylates are used for their anti-inflammatory and antipyretic properties and to treat less severe pain.
The hospital administrator had undergone percutaneous transhepatic cholangiography. which assessment finding indicates complication after the operation? A. Fever and chills B. Hypertension C. Bradycardia D. Nausea and diarrhea
Answer: A Septicemia is a common complication after a percutaneous transhepatic cholangiography. Evidence of fever and chills, possibly indicative of septicemia, is important. HYpotension, not hypertension, is associated with septicemia. Tachycardia, not bradycardia, is most likely to occur. Nausea and diarrhea may occur but are not classic signs of sepsis.
A 72-year old male client is brought to the emergency room by his son. The client is extremely uncomfortable and has been unable to void for the past 12 hours. He has known for some time that he has an enlarged prostate but has wanted to avoid surgery. The best method for the nurse to use when assessing for bladder distention in a male client is to check for: A. A rounded swelling above the pubis. B. Dullness in the lower left quadrant C. Rebound tenderness below the symphysis D. Urine discharge from the urethral meatus
Answer: A The best way to assess for a distended bladder in either a male or female client is to check for a rounded swelling above the pubis. The swelling represents the distended bladder rising above the pubis into the abdominal cavity. Dullness does not indicate a distended bladder. The client might experience tenderness or pressure above the symphysis. No urine discharge is expected; the urine flow is blocked by the enlarged prostate.
A nurse is assigned to care for a client with nephrotic syndrome. The nurse assesses which important parameter on a daily basis? a) weight b) albumin levels c) activity tolerance d) blood urea nitrogen (BUN) level
Answer: A The client with nephrotic syndrome typically presents with edema, hypoalbuminemia, and proteinuria. The nurse carefully assesses the fluid balance of the client, which includes daily monitoring of weight, intake and output, edema, and girth measurements. Albumin levels are monitored as they are prescribed, as are the BUN and creatinine levels. The client's activity level is adjusted according to the amount of edema and water retention. As edema increases, the client's activity level should be restricted.
A male client comes to the emergency department complaining of sudden onset of sharp, severe pain in the lumbar region, which radiates around the side and toward the bladder. The client also reports nausea and vomiting and appears pale, diaphoretic, and anxious. The physician tentatively diagnosed renal calculi and orders flat-plate abdominal X-rays. Renal calculi can form anywhere in the urinary tract. What is their most common formation site? A Kidney B Ureter C Bladder D Urethra
Answer: A The most common site of renal calculi formation is the kidney. Calculi may travel down the urinary tract with or without causing damage and may lodge anywhere along the tract or may stay within the kidney. The ureter, bladder, and urethra are less common sites of renal calculi formation.
The primary reason for taping an indwelling catheter laterally to the thigh of a male client is to: A. Eliminate pressure at the penoscrotal angle B. Prevent the catheter from kinking in the urethra C. Prevent accidental catheter removal D. Allow the client to turn without kinking the catheter
Answer: A The primary reason for taping an indwelling catheter to a male client soothe penis is held in a lateral position to prevent pressure at the penoscrotal angle. Prolonged pressure at the penoscrotal angle can cause a ureterocutaneous fistula.
The client with BPH undergoes a transurethral resection of the prostate. Postoperatively, the client is receiving continuous bladder irrigations. The nurse assesses the client for signs of transurethral resection syndrome. Which of the following assessment data would indicate the onset of this syndrome? A. Bradycardia and confusion B. Tachycardia and diarrhea C. Decreased urinary output and bladder spasms D. Increased urinary output and anemia
Answer: A Transurethral resection syndrome is caused by increased absorption of nonelectrolyte irrigating fluid used during surgery. The client may show signs of cerebral edema and increased intracranial pressure such as increased blood pressure, bradycardia, confusion, disorientation, muscle twitching, visual disturbances, and nausea and vomiting.
A client is complaining of severe flank and abdominal pain. A flat plate of the abdomen shows urolithiasis. Which of the following interventions is important? A. Strain all urine B. Limit fluid intake C. Enforce strict bed rest D. Encourage a high calcium diet
Answer: A Urine should be strained for calculi and sent to the lab for analysis. Fluid intake of 3 to 4 L is encouraged to flush the urinary tract and prevent further calculi formation. A low-calcium diet is recommended to help prevent the formation of calcium calculi. Ambulation is encouraged to help pass the calculi through gravity.
What change indicates recovery in a patient with nephrotic syndrome? A. Disappearance of protein from the urine B. Decrease in blood pressure to normal C. Increase in serum lipid levels D. Gain in body weight
Answer: A With nephrotic syndrome, the glomerular basement membrane of the kidney becomes more porous, leading to loss of protein in the urine. As the patient recovers, less protein is found in the urine.
A male client with cholelithiasis has a gallstone lodged in the common bile duct. When assessing this client, the nurse expects to note: A. yellow sclera B. light amber urine C. circumoral pallor D. black, tarry stools.
Answer: A Yellow sclerae may be the first sign of jaundice, which occurs when the common bile duct is obstructed. Urine normally is light amber. Circumoral pallor and black, tarry stools don't occur in common bile duct obstruction; they are signs of hypoxia and GI bleeding, respectively.
The client is admitted to the ER following a MVA. The client was wearing a lap seat belt when the accident occurred. The client has hematuria and lower abdominal pain. To determine further whether the pain is due to bladder trauma, the nurse asks the client if the pain is referred to which of the following areas? A. Shoulder B. Umbilicus C. Costovertebral angle D. Hip
Answer: A lower abdominal pain that may radiate to one of the shoulders
Allopurinol (Zyloprim), 200 mg/day, is prescribed for the client with renal calculi to take home. The nurse should teach the client about which of the following side effects of this medication? A. Retinopathy B. Maculopapular rash C. Nasal congestion D. Dizziness
Answer: B Allopurinol is used to treat renal calculi composed of uric acid. Side effects of allopurinol include drowsiness, maculopapular rash, anemia, abdominal pain, nausea, vomiting, and bone marrow depression. Clients should be instructed to report skin rashes and any unusual bleeding or bruising. Retinopathy, nasal congestion, and dizziness are not side effects of allopurinol.
After undergoing a transurethral resection of the prostate to treat benign prostatic hypertrophy, a patient is retuned to the room with continuous bladder irrigation in place. One day later, the patient reports bladder pain. What should the nurse do first? A. Notify the doctor immediately B. Assess the irrigation catheter for patency and drainage C. Increase the I.V. flow rate D. Administer meperidine (Demerol) as prescribed
Answer: B Although postoperative pain is expected, the nurse should ensure that other factors, such as an obstructed irrigation catheter, aren't the cause of the pain. After assessing catheter patency, the nurse should administer an analgesic such as meperidine as prescribed. Increasing the I.V. flow rate may worse the pain. Notifying the doctor isn't necessary unless the pain is severe or unrelieved by the prescribed medication.
For Jayvin who is taking antacids, which instruction would be included in the teaching plan? A. "Take the antacids with 8 oz of water." B. "Avoid taking other medications within 2 hours of this one." C. "Continue taking antacids even when pain subsides." D. "Weigh yourself daily when taking this medication.
Answer: B Antacids neutralize gastric acid and decrease the absorption of other medications. The client should be instructed to avoid taking other medications within 2 hours of the antacid. Water, which dilutes the antacid, should not be taken with antacid. A histamine receptor antagonist should be taken even when pain subsides. Daily weights are indicated if the client is taking a diuretic, not an antacid.
For Rico who has chronic pancreatitis, which nursing intervention would be most helpful? A. Allowing liberalized fluid intake B. Counseling to stop alcohol consumption C. Encouraging daily exercise D. Modifying dietary protein
Answer: B Chronic pancreatitis typically results from repeated episodes of acute pancreatitis. More than half of chronic pancreatitis cases are associated with alcoholism. Counseling to stop alcohol consumption would be the most helpful for the client. Dietary protein modification is not necessary for chronic pancreatitis. Daily exercise and liberalizing fluid intake would be helpful but not the most beneficial intervention.
A nurse is giving a client with polycystic kidney disease instructions in replacing elements lost in the urine as a result of impaired kidney function. The nurse instructs the client to increase intake of which of the following in the client? a) sodium and potassium b) sodium and water c) water and phosphorus d) calcium and phosphorus
Answer: B Clients with polycystic kidney disease waste sodium rather than retain it and therefore need an increase in sodium and water in the diet. Potassium, calcium, and phosphorus do not need to be increased in this condition.
Which of the following symptoms do you expect to see in a patient diagnosed with acute pyelonephritis? A. Jaundice and flank pain B. Costovertebral angle tenderness and chills C. Burning sensation on urination D. Polyuria and nocturia
Answer: B Costovertebral angle tenderness, flank pain, and chills are symptoms of acute pyelonephritis. Jaundice indicates gallbladder or liver obstruction. A burning sensation on urination is a sign of lower urinary tract infection.
What laboratory finding is the primary diagnostic indicator for pancreatitis? A. Elevated blood urea nitrogen (BUN) B. Elevated serum lipase C. Elevated aspartate aminotransferase (AST) D. Increased lactate dehydrogenase (LD)
Answer: B Elevation of serum lipase is the most reliable indicator of pancreatitis because this enzyme is produced solely by the pancreas. A client's BUN is typically elevated in relation to renal dysfunction; the AST, in relation to liver dysfunction; and LD, in relation to damaged cardiac muscle.
A client with nephrolithiasis arrives at a clinic for a follow-up visit. The laboratory analysis of the stone that the client passed 1 week ago indicates that the stone is composed of calcium oxalate. The nurse tells the client to avoid consuming which food item? a) lentils b) strawberries c) lettuce d) pasta
Answer: B Foods that raise urinary oxalate excretion include spinach, rhubarb, strawberries, chocolate, wheat bran, nuts, beets, and tea. Of the options provided, the client will be instructed to avoid strawberries.
A male client with pancreatitis complains of pain. The nurse expects the physician to prescribe meperidine (Demerol) instead of morphine to relieve pain because: A. meperidine provides a better, more prolonged analgesic effect. B. morphine may cause spasms of Oddi's sphincter. C. meperidine is less addictive than morphine. D. morphine may cause hepatic dysfunction.
Answer: B For a client with pancreatitis, the physician will probably avoid prescribing morphine because this drug may trigger spasms of the sphincter of Oddi (a sphincter at the end of the pancreatic duct), causing irritation of the pancreas. Meperidine has a somewhat shorter duration of action than morphine. The two drugs are equally addictive. Morphine isn't associated with hepatic dysfunction
The client returns to the nursing unit following a pyelolithotomy for removal of a kidney stone. A Penrose drain is in place. Which of the following would the nurse include on the client's postoperative care? A. Sterile irrigation of the Penrose drain B. Frequent dressing changes around the Penrose drain C. Weighing the dressings D. Maintaining the client's position on the affected side
Answer: B Frequent dressing changes around the Penrose drain is required to protect the skin against breakdown from urinary drainage. If urinary drainage is excessive, an ostomy pouch may be placed over the drain to protect the skin. A Penrose drain is not irrigated. Weighing the dressings is not necessary. Placing the client on the affected side will prevent a free flow of urine through the drain.
Which condition is most likely to have a nursing diagnosis of fluid volume deficit? A. Appendicitis B. Pancreatitis C. Cholecystitis D. Gastric ulcer
Answer: B Hypovolemic shock from fluid shifts is a major factor in acute pancreatitis.
A client who has been diagnosed with calculi reports that the pain is intermittent and less colicky. Which of the following nursing actions is most important at this time? A. Report hematuria to the physician B. Strain the urine carefully C. Administer meperidine (Demerol) every 3 hours D. Apply warm compresses to the flank area
Answer: B Intermittent pain that is less colicky indicates that the calculi may be moving along the urinary tract. Fluids should be encouraged to promote movement, and the urine should be strained to detect passage of the stone. Hematuria is to be expected from the irritation of the stone. Analgesics should be administered when the client needs them, not routinely. Moist heat to the flank area is helpful when renal colic occurs, but it is less necessary as pain is lessened.
Nurse Pete is reviewing the report of a client's routine urinalysis. Which value should the nurse consider abnormal? A. Specific gravity of 1.03 B. Urine pH of 3.0 C. Absence of protein D. Absence of glucose
Answer: B Normal urine pH is 4.5 to 8; therefore, a urine pH of 3.0 is abnormal. Urine specific gravity normally ranges from 1.002 to 1.035, making this client's value normal. Normally, urine contains no protein, glucose, ketones, bilirubin, bacteria, casts, or crystals. Red blood cells should measure 0 to 3 per high-power field; white blood cells, 0 to 4 per high-power field. Urine should be clear, its color ranging from pale yellow to deep amber.
Of the options below, which is NOT a symptom of BPH? A. Urinary incontinence B. Intestinal pain C. Difficulty urinating D. Sexual dysfunction
Answer: B Recent studies suggest that there is a correlation between lower urinary tract symptoms and sexual dysfunction in aging patients. In fact, the severity of urinary symptoms and the degree of sexual dysfunction are strongly correlated, indepently of age. In particular, community-based studies have found that a significant number of patients with symptomatic BPH have sexual dysfunction.
After having transurethral resection of the prostate (TURP), a Mr. Lim returns to the unit with a three-way indwelling urinary catheter and continuous closed bladder irrigation. Which finding suggests that the client's catheter is occluded? A. The urine in the drainage bag appears red to pink B. The client reports bladder spasms and the urge to void C. The normal saline irrigant is infusing at a rate of 50 drops/minute D. About 1,000 ml of irrigant have been instilled; 1,200 ml of drainage have been returned
Answer: B Reports of bladder spasms and the urge to void suggest that a blood clot may be occluding the catheter. After TURP, urine normally appears red to pink, and normal saline irrigant usually is infused at a rate of 40 to 60 drops/minute or according to facility protocol. The amount of retained fluid (1,200 ml) should correspond to the amount of instilled fluid, plus the client's urine output (1,000 ml + 200 ml), which reflects catheter patency.
Romeo Diaz, age 78, is admitted to the hospital with the diagnosis of benign prostatic hyperplasia (BPH). He is scheduled for a transurethral resection of the prostate (TURP). It would be inappropriate to include which of the following points in the preoperative teaching? A. Expect bloody urine, which will clear as healing takes place. B. He will be pain free. C. Explain the purpose and function of a two-way irrigation system. D. TURP is the most common operation for BPH
Answer: B Surgical interventions involve an experience of pain for the client which can come in varying degrees. Telling the pain that he will be pain free is giving him false reassurance.
A nurse has provided instructions to a client with a nephrotostomy tube regarding home care after hospital discharge. The nurse determines that the client understands the instructions if the client verbalizes to drink approximately how many 8-ounce glasses of water per day? a) 2 b) 8 c) 16 d) 20
Answer: B The client with a nephrostomy tube needs to have adequate fluid intake to dilute urinary particles that could cause calculus and to provide mechanical flushing of the kidney and tube. The nurse encourages the client to take in 2000 mL of fluid per day, which is roughly equivalent to eight 8-ounce glasses of water. Option A identifies a fluid intake volume that is too low and would not provide mechanical flushing of the kidney and tube. Options C and D identify very large volumes of fluid intake; these volumes are unnecessary and could possibly place undo distention on the renal pelvis.
The nurse is conducting a postoperative assessment of a client on the first day after renal surgery. Which of the following findings would be most important for the nurse to report to the physician? A. Temperature, 99.8 B. Urine output, 20 ml/hour C. Absence of bowel sounds D. A 2×2 inch area of serous sanguineous drainage on the flank dressing.
Answer: B The decrease in urinary output may indicate inadequate renal perfusion and should be reported immediately. Urine output of 30 ml/hour or greater is considered acceptable. A slight elevation in temperature is expected after surgery. Peristalsis returns gradually, usually the second or third day after surgery. Bowel sounds will be absent until then. A small amount of serous sanguineous drainage is to be expected.
If a client's prostate enlargement is caused by a malignancy, which of the following blood examinations should the nurse anticipate to assess whether metastasis has occurred? A. Serum creatinine level B. Serum acid phosphatase level C. Total nonprotein nitrogen level D. Endogenous creatinine clearance time
Answer: B The most specific examination to determine whether a malignancy extends outside of the prostatic capsule is a study of the serum acid phosphatase level. The level increases when a malignancy has metastasized. The prostate specific antigen (PSA) determination and a digital rectal examination are done when screening for prostate cancer. Serum creatinine level, total nonprotein nitrogen level, and endogenous creatinine clearance time give information about kidney function, not prostate malignancy.
The most common early sign of kidney disease is: A. Sodium retention B. Elevated BUN level C. Development of metabolic acidosis D. Inability to dilute or concentrate urine
Answer: B increased BUN is usually an early indicator of decreased renal function
When evaluating a male client for complications of acute pancreatitis, the nurse would observe for: A. increased intracranial pressure B. decreased urine output C. bradycardia D. hypertension
Answer: B Acute pancreatitis can cause decreased urine output, which results from the renal failure that sometimes accompanies this condition. Intracranial pressure neither increases nor decreases in a client with pancreatitis. Tachycardia, not bradycardia, usually is associated with pulmonary or hypovolemic complications of pancreatitis. Hypotension can be caused by a hypovolemic complication, but hypertension usually isn't related to acute pancreatitis.
The nurse is taking the history of a client who has had benign prostatic hyperplasia in the past. To determine whether the client currently is experiencing difficulty, the nurse asks the client about the presence of which of the following early symptoms? a. Urge incontinence b. Nocturia c. Decreased force in the stream of urine d. Urinary retention
Answer: C Decreased force in the stream of urine is an early sign of BPH. The stream later becomes weak and dribbling. The client then may develop hematuria, frequency, urgency, urge incontinence, and nocturia. If untreated, complete obstruction and urinary retention can occur.
The nurse is receiving in transfer from the postanesthesia care unit a client who has had a percutaneous ultrasonic lithotripsy for calculuses in the renal pelvis. The nurse anticipates that the client's care will involve monitoring which of the following? A. Suprapubic tube B. Urethral stent C. Nephrostomy tube D. Jackson-Pratt drain
Answer: C A nephrostomy tube is put in place after a percutaneous ultrasonic lithotripsy to treat calculuses in the renal pelvis. The client may also have a foley catheter to drain urine produced by the other kidney. The nurse monitors the drainage from each of these tubes and strains the urine to detect elimination of the calculus fragments.
A client who has a renal mass asks the nurse why an ultrasound has been scheduled, as opposed to other diagnostic tests that may be ordered. The nurse formulates a response based on the understanding that: a) all other tests are more invasive than an ultrasound b) all other tests require more elaborate postprocedure care c) an ultrasound can differentiate a solid mass from a fluid-filled cyst d) an ultrasound is much more cost effective than other diagnostic tests
Answer: C A significant advantage of an ultrasound is that it can differentiate a solid mass from a fluid-filled cyst. It is noninvasive and does not require any special aftercare. Other diagnostic tests, such as magnetic resonance imaging and computed tomography scanning, are also noninvasive (unless contrast is used) and require no special aftercare, either. However, the ultrasound can discriminate between solid and fluid masses most optimally.
The nurse is reviewing a medication history of a client with BPH. Which medication should be recognized as likely to aggravate BPH? A. Metformin (Glucophage) B. Buspirone (BuSpar) C. Inhaled ipratropium (Atrovent) D. Ophthalmic timolol (Timoptic)
Answer: C Atrovent is a bronchodilator, and its anticholinergic effects can aggravate urinary retention. Glucophage and BuSpar do not affect the urinary system; timolol does not have a systemic effect.
The nurse is taking the history of a client who has had benign prostatic hyperplasia in the past. To determine whether the client currently is experiencing difficulty, the nurse asks the client about the presence of which of the following early symptoms? A Urge incontinence B Nocturne C Decreased force in the stream of urine D Urinary retention
Answer: C Decreased force in the stream of urine is an early sign of BPH. The stream later becomes weak and dribbling. The client then may develop hematuria, frequency, urgency, urge incontinence, and nocturia. If untreated, complete obstruction and urinary retention can occur.
Marie, a 51-year-old woman, is diagnosed with cholecystitis. Which diet, when selected by the client, indicates that the nurse's teaching has been successful? A. 4-6 small meals of low-carbohydrate foods daily B. High-fat, high-carbohydrate meals C. Low-fat, high-carbohydrate meals D. High-fat, low protein meals
Answer: C For the client with cholecystitis, fat intake should be reduced. The calories from fat should be substituted with carbohydrates. Reducing carbohydrate intake would be contraindicated. Any diet high in fat may lead to another attack of cholecystitis.
The client is admitted to the hospital with BPH, and a transurethral resection of the prostate is performed. Four hours after surgery the nurse takes the client's VS and empties the urinary drainage bag. Which of the following assessment findings would indicate the need to notify the physician? A. Red bloody urine B. Urinary output of 200 ml greater than intake C. Blood pressure of 100/50 and pulse 130 D. Pain related to bladder spasms
Answer: C Frank bleeding (arterial or venous) may occur during the first few days after surgery. Some hematuria is usual for several days after surgery. A urinary output of 200 ml of greater than intake is adequate. Bladder spasms are expected to occur after surgery. A rapid pulse with a low blood pressure is a potential sign of excessive blood loss. The physician should be notified.
Clinical manifestations of acute glomerulonephritis include which of the following? A. Chills and flank pain B. Oliguria and generalized edema C. Hematuria and proteinuria D. Dysuria and hypotension
Answer: C Hematuria and proteinuria indicate acute glomerulonephritis. These finding result from increased permeability of the glomerular membrane due to the antigen-antibody reaction. Generalized edema is seen most often in nephrosis.
Which finding leads you to suspect acute glomerulonephritis in your 32 y.o. patient? A. Dysuria, frequency, and urgency B. Back pain, nausea, and vomiting C. Hypertension, oliguria, and fatigue D. Fever, chills, and right upper quadrant pain radiating to the back
Answer: C Mild to moderate HTN may result from sodium or water retention and inappropriate renin release from the kidneys. Oliguria and fatigue also may be seen. Other signs are proteinuria and azotemia.
The client passes a urinary stone, and lab analysis of the stone indicates that it is composed of calcium oxalate. Based on this analysis, which of the following would the nurse specifically include in the dietary instructions? A. Increase intake of meat, fish, plums, and cranberries B. Avoid citrus fruits and citrus juices C. Avoid green, leafy vegetables such as spinach D. Increase intake of dairy product
Answer: C Oxalate is found in dark green foods such as spinach. Other foods that raise urinary oxalate are rhubarb, strawberries, chocolate, wheat bran, nuts, beets, and tea.
The nurse is aware that the following laboratory values supports a diagnosis of pyelonephritis? A. Myoglobinuria B. Ketonuria C. Pyuria D. Low white blood cell (WBC) count
Answer: C Pyelonephritis is diagnosed by the presence of leukocytosis, hematuria, pyuria, and bacteriuria. The client exhibits fever, chills, and flank pain. Because there is often a septic picture, the WBC count is more likely to be high rather than low, as indicated in option D. Ketonuria indicates a diabetic state.
The client with urolithiasis has a history of chronic urinary tract infections. The nurse concludes that this client most likely has which of the following types of urinary stones? A. Calcium oxalate B. Uric acid C. Struvite D. Cystine
Answer: C Struvite stones commonly are referred to as infection stones because they form in urine that is alkaline and rich in ammonia, such as with a urinary tract infection. Calcium oxalate stones result from increased calcium intake or conditions that raise serum calcium concentrations. Uric acid stones occur in clients with gout. Cystine stones are rare and occur in clients with a genetic defect that results in decreased renal absorption of the amino acid cystine.
A client with BPH is being treated with terazosin (Hytrin) 2 mg at bedtime. The nurse should monitor the client's: A. Urinary nitrites B. White blood cell count C. Blood pressure D. Pulse
Answer: C Terazosin (Hytrin) is an antihypertensive drug that is also used in the treatment of BPH. Blood pressure must be monitored to ensure that the client does not develop hypotension, syncope, or postural hypotension. The client should be instructed to change positions slowly. Urinary nitrites, white blood cell count, and pulse rate are not affected by terazosin.
A client has passed a renal calculus. The nurse sends the specimen to the laboratory so it can be analyzed for which of the following factors? A. Antibodies B. Type of infection C. Composition of calculus D. Size and number of calculi
Answer: C The calculus should be analyzed for composition to determine appropriate interventions such as dietary restrictions. Calculi don't result in infections. The size and number of calculi aren't relevant, and they don't contain antibodies.
A client has passed a renal calculus. The nurse sends the specimen to the laboratory so it can be analyzed for which of the following factors? a. Antibodies b. Type of infection c. Composition of calculus d. Size and number of calculi
Answer: C The calculus should be analyzed for composition to determine appropriate interventions such as dietary restrictions. Calculi don't result in infections. The size and number of calculi aren't relevant, and they don't contain antibodies.
An eighty five year old man was admitted for surgery for benign prostatic hypertrophy. Preoperatively he was alert, oriented, cooperative, and knowledgeable about his surgery. Several hours after surgery, the evening nurse found him acutely confused, agitated, and trying to climb over the protective side rails on his bed. The most appropriate nursing intervention that will calm an agitated client is A. encourage family phone calls. B. Position in a bright, busy area. C. Speak soothingly and provide quiet music. D. Limit visits by staff
Answer: C The client needs frequent visits by the staff to orient him and to assess his safety. Phone calls from his family will not help a client who is trying to climb over the side rails and may even add to his danger. Putting the client in a bright, busy area would probably add to his confusion. The environment is an important factor in the prevention of injuries. Talking softly and providing quiet music have a calming effect on the agitated client.
Nurse Harry is providing postprocedure care for a client who underwent percutaneous lithotripsy. In this procedure, an ultrasonic probe inserted through a nephrostomy tube into the renal pelvis generates ultra-high-frequency sound waves to shatter renal calculi. The nurse should instruct the client to: A. limit oral fluid intake for 1 to 2 weeks. B. report the presence of fine, sand-like particles through the nephrostomy tube. C. notify the physician about cloudy or foul-smelling urine. D. report bright pink urine within 24 hours after the procedure.
Answer: C The client should report the presence of foul-smelling or cloudy urine. Unless contraindicated, the client should be instructed to drink large quantities of fluid each day to flush the kidneys. Sand-like debris is normal due to residual stone products. Hematuria is common after lithotripsy
A client underwent a TURP, and a large three way catheter was inserted in the bladder with continuous bladder irrigation. In which of the following circumstances would the nurse increase the flow rate of the continuous bladder irrigation? A. When the drainage is continuous but slow B. When the drainage appears cloudy and dark yellow C. When the drainage becomes bright red D. When there is no drainage of urine and irrigating solution
Answer: C The decision made by the surgeon to insert a catheter after a TURP or prostatectomy depends on the amount of bleeding that is expected after the procedure. During continuous bladder irrigation after a TURP or prostatectomy, the rate at which the solution enters the bladder should be increased when the drainage becomes brighter red. The color indicates the presence of blood. Increasing the flow of irrigating solution helps flush the catheter well so clots do not plug it. There would be no reason to increase the flow rate when the return is continuous or when the return appears cloudy and dark yellow. Increasing the flow would be contraindicated when there is no return of urine and irrigating solution.
Pierre who is diagnosed with acute pancreatitis is under the care of Nurse Bryan. Which intervention should the nurse include in the care plan for the client? A. Administration of vasopressin and insertion of a balloon tamponade B. Preparation for a paracentesis and administration of diuretics C. Maintenance of nothing-by-mouth status and insertion of nasogastric (NG) tube with low intermittent suction D. Dietary plan of a low-fat diet and increased fluid intake to 2,000 ml/day
Answer: C With acute pancreatitis, the client is kept on nothing-by-mouth status to inhibit pancreatic stimulation and secretion of pancreatic enzymes. NG intubation with low intermittent suction is used to relieve nausea and vomiting, decrease painful abdominal distention, and remove hydrochloric acid. Vasopressin would be appropriate for a client diagnosed with bleeding esophageal varices. Paracentesis and diuretics would be appropriate for a client diagnosed with portal hypertension and ascites. A low-fat diet and increased fluid intake would further aggravate the pancreatitis
What question would be most important to ask a male client who is in for a digital rectal examination? A. "Have you noticed a change in tolerance of certain foods in your diet?" B. "Do you notice any burning with urination or any odor to the urine?" C. "Have you noticed a change in the force of the urinary system?" D. "Do you notice polyuria in the AM?"
Answer: C most likely to be indicative of BPH
Alpha blockers in the treatment of BPH are associated with all of the following except: A. Once daily dosing B. Minimal changes in blood pressure C. Side effects of dizziness and fatigue D. 25% decrease in prostate size E. Improvment in symptoms in 2-3 weeks
Answer: D
A female client with a urinary diversion tells the nurse, "This urinary pouch is embarrassing. Everyone will know that I'm not normal. I don't see how I can go out in public anymore." The most appropriate nursing diagnosis for this patient is: A. Anxiety related to the presence of urinary diversion. B. Deficient Knowledge about how to care for the urinary diversion. C. Low Self-Esteem related to feelings of worthlessness D. Disturbed Body Image related to creation of a urinary diversion.
Answer: D It is normal for clients to express fears and concerns about the body changes associated with a urinary diversion. Allowing the client time to verbalize concerns in a supportive environment and suggest that she discuss these concerns with people who have successfully adjusted to ostomy surgery can help her begin coping with these changes in a positive manner. Although the client may be anxious about this situation and self-esteem may be diminished, the underlying problem is disturbance in body image. There are no data to support a diagnosis of Deficient Knowledge.
The client who has a cold is seen in the emergency room with inability to void. Because the client has a history of BPH, the nurse determines that the client should be questioned about the use of which of the following medications? a. Diuretics b. Antibiotics c. Antitussives d. Decongestants
Answer: D In the client with BPH, episodes of urinary retention can be triggered by certain medications, such as decongestants, anticholinergics, and antidepressants. The client should be questioned about the use of these medications if the client has urinary retention. Retention can also be precipitated by other factors, such as alcoholic beverages, infection, bedrest, and becoming chilled.
Which clinical manifestation would the nurse expect a client diagnosed with acute cholecystitis to exhibit? A. Jaundice, dark urine, and steatorrhea B. Acute right lower quadrant (RLQ) pain, diarrhea, and dehydration C. Ecchymosis petechiae, and coffee-ground emesis D. Nausea, vomiting, and anorexia
Answer: D Acute cholecystitis is an acute inflammation of the gallbladder commonly manifested by the following: anorexia, nausea, and vomiting; biliary colic; tenderness and rigidity the right upper quadrant (RUQ) elicited on palpation (e.g., Murphy's sign); fever; fat intolerance; and signs and symptoms of jaundice. Ecchymosis, petechiae, and coffee-ground emesis are clinical manifestations of esophageal bleeding. The coffee-ground appearance indicates old bleeding. Jaundice, dark urine, and steatorrhea are clinical manifestations of the icteric phase of hepatitis
Which intervention do you plan to include with a patient who has renal calculi? A. Maintain bed rest B. Increase dietary purines C. Restrict fluids D. Strain all urine
Answer: D All urine should be strained through gauze or a urine strainer to catch stones that are passed. The stones are then analyzed for composition. Ambulation may help the movement of the stone down the urinary tract. Encourage fluid to help flush the stones out.
A client had a transurethral prostatectomy for benign prostatic hypertrophy. He's currently being treated with a continuous bladder irrigation and is complaining of an increase in severity of bladder spasms. Which of the interventions should be done first? A. Administer an oral analgesic B. Stop the irrigation and call the physician C. Administer a belladonna and opium suppository as ordered by the physician D. Check for the presence of clots, and make sure the catheter is draining properly
Answer: D Blood clots and blocked outflow if the urine can increase spasms. The irrigation shouldn't be stopped as long as the catheter is draining because clots will form. A belladonna and opium suppository should be given to relieve spasms but only after assessment of the drainage. Oral analgesics should be given if the spasms are unrelieved by the belladonna and opium suppository.
A client is receiving a radiation implant for the treatment of bladder cancer. Which of the following interventions is appropriate? A. Flush all urine down the toilet B. Restrict the client's fluid intake C. Place the client in a semi-private room D. Monitor the client for signs and symptoms of cystitis
Answer: D Cystitis is the most common adverse reaction of clients undergoing radiation therapy; symptoms include dysuria, frequency, urgency, and nocturia. Clients with radiation implants require a private room. Urine of clients with radiation implants for bladder cancer should be sent to the radioisotopes lab for monitoring. It is recommended that fluid intake be increased.
The nurse caring for a client with small-bowel obstruction would plan to implement which nursing intervention first? A. Administering pain medication B. Obtaining a blood sample for laboratory studies C. Preparing to insert a nasogastric (NG) tube D. Administering I.V. fluids
Answer: D I.V. infusions containing normal saline solution and potassium should be given first to maintain fluid and electrolyte balance. For the client's comfort and to assist in bowel decompression, the nurse should prepare to insert an NG tube next. A blood sample is then obtained for laboratory studies to aid in the diagnosis of bowel obstruction and guide treatment. Blood studies usually include a complete blood count, serum electrolyte levels, and blood urea nitrogen level. Pain medication often is withheld until obstruction is diagnosed because analgesics can decrease intestinal motility.
A client is scheduled to undergo a transurethral resection of the prostate gland (TURP). The procedure is to be done under spinal anesthesia. Postoperatively, the nurse should be particularly alert for early signs of: A. Convulsions B. Cardiac arrest C. Renal shutdown D. Respiratory paralysis
Answer: D If paralysis of vasomotor nerves in the upper spinal cord occurs when spinal anesthesia is used, the client is likely to develop respiratory paralysis. Artificial ventilation is required until the effects of the anesthesia subside. Convulsions, cardiac arrest, and renal shutdown are not likely results of spinal anesthesia.
The client who has a cold is seen in the emergency room with inability to void. Because the client has a history of BPH, the nurse determines that the client should be questioned about the use of which of the following medications? A Diuretics B Antibiotics C Antitussives D Decongestants
Answer: D In the client with BPH, episodes of urinary retention can be triggered by certain medications, such as decongestants, anticholinergics, and antidepressants. The client should be questioned about the use of these medications if the client has urinary retention. Retention can also be precipitated by other factors, such as alcoholic beverages, infection, bedrest, and becoming chilled.
Your patient has complaints of severe right-sided flank pain, nausea, vomiting and restlessness. He appears slightly pale and is diaphoretic. Vital signs are BP 140/90 mmHg, Pulse 118 beats/min., respirations 33 breaths/minute, and temperature, 98.0F. Which subjective data supports a diagnosis of renal calculi? A. Pain radiating to the right upper quadrant B. History of mild flu symptoms last week C. Dark-colored coffee-ground emesis D. Dark, scanty urine output
Answer: D Patients with renal calculi commonly have blood in the urine caused by the stone's passage through the urinary tract. The urine appears dark, tests positive for blood, and is typically scant.
A client is admitted with a diagnosis of hydronephrosis secondary to calculi. The calculi have been removed and postobstructive diuresis is occurring. Which of the following interventions should be done? A. Take vital signs every 8 hours B. Weigh the client every other day C. Assess for urine output every shift D. Monitor the client's electrolyte levels
Answer: D Postobstructive diuresis seen in hydronephrosis can cause electrolyte imbalances; lab values must be checked so electrolytes can be replaced as needed. VS should initially be taken every 30 minutes for the first 4 hours and then every 2 hours. Urine output needs to be assessed hourly. The client's weight should be taken daily to assess fluid status more closely.
A client is admitted with a diagnosis of hydronephrosis secondary to calculi. The calculi have been removed and postobstructive diuresis is occurring. Which of the following interventions should be done? a. Take vital signs every 8 hours b. Weigh the client every other day c. Assess for urine output every shift d. Monitor the client's electrolyte levels.
Answer: D Postobstructive diuresis seen in hydronephrosis can cause electrolyte imbalances; lab values must be checked so electrolytes can be replaced as needed. VS should initially be taken every 30 minutes for the first 4 hours and then every 2 hours. Urine output needs to be assessed hourly. The client's weight should be taken daily to assess fluid status more closely.
Nurse Hannah is teaching a group of middle-aged men about peptic ulcers. When discussing risk factors for peptic ulcers, the nurse should mention: A. a sedentary lifestyle and smoking. B. a history of hemorrhoids and smoking C. alcohol abuse and a history of acute renal failure D. alcohol abuse and smoking
Answer: D Risk factors for peptic (gastric and duodenal) ulcers include alcohol abuse, smoking, and stress. A sedentary lifestyle and a history of hemorrhoids aren't risk factors for peptic ulcers. Chronic renal failure, not acute renal failure, is associated with duodenal ulcers.
The obstructive and irritative symptom complex caused by benign prostatic hypertrophy is termed A. prostaglandin. B. prostatectomy. C. Prostatitis. D. prostatism
Answer: D Symptoms of prostatism include increased frequency of urination, nocturia, urgency, dribbling, and a sensation that the bladder has not completely emptied. Prostatitis is an inflammation of the prostate gland.Prostaglandins are physiologically active substances present in tissues with vasodilator properties. Prostatectomy refers to the surgical removal of the prostate gland.
While palpating a female client's right upper quadrant (RUQ), the nurse would expect to find which of the following structures? A. Sigmoid colon B. Appendix C. Spleen D. Liver
Answer: D The RUQ contains the liver, gallbladder, duodenum, head of the pancreas, hepatic flexure of the colon, portions of the ascending and transverse colon, and a portion of the right kidney. The sigmoid colon is located in the left lower quadrant; the appendix, in the right lower quadrant; and the spleen, in the left upper quadrant
Jordin is a client with jaundice who is experiencing pruritus. Which nursing intervention would be included in the care plan for the client? A. Administering vitamin K subcutaneously B. Applying pressure when giving I.M. injections C. Decreasing the client's dietary protein intake D. Keeping the client's fingernails short and smooth
Answer: D The client with pruritus experiences itching, which may lead to skin breakdown and possibly infection from scratching. Keeping his fingernails short and smooth helps prevent skin breakdown and infection from scratching. Applying pressure when giving I.M. injections and administering vitamin K subcutaneously are important if the client develops bleeding problems. Decreasing the client's dietary intake is appropriate if the client's ammonia levels are increased.
A client is being admitted to the hospital with a diagnosis of urolithiasis and ureteral colic. The nurse assesses the client for pain that is: a) dull and aching in the costovetebal area b) aching and camplike throughout the abdomen c) sharp and radiating posteriorly to the spinal column d) excruciating, wavelike, and radiating toward the genitalia
Answer: D The pain of ureteral colic is caused by movement of a stone through the ureter and is sharp, excruciating, and wavelike, radiating to the genitalia and thigh. The stone causes reduced flow of urine, and the urine also contains blood because of its abrasive action on urinary tract mucosa. Stones in the renal pelvis cause pain that is a deep ache in the costovertebral area. Renal colic is characterized by pain that is acute, with tenderness over the costovertebral area.
A client has been admitted to the hospital with a diagnosis of acute glomerulonephritis. During history-taking the nurse first asks the client about a recent history of: a) bleeding ulcer b) deep vein thrombosis c) myocardial infarction d) streptococcal infection
Answer: D The predominant cause of acute glomerulonephritis is infection with beta hemolytic Streptococcus 3 weeks before the onset of symptoms. In addition to bacteria, other infectious agents that could trigger the disorder include viruses, fungi, and parasites. Bleeding ulcer, deep vein thrombosis, and myocardial infarction are not precipitating causes.
A client is admitted to the hospital with benign prostatic hyperplasia, the nurse most relevant assessment would be: A. Flank pain radiating in the groin B. Urethral discharge C. Perineal edema D. Distention of the lower abdomen
Answer: D This indicates that the bladder is distended with urine, therefore palpable
The nurse is administering a psychotropic drug to an elderly client who has history of benign prostatic hypertrophy. It is most important for the nurse to teach this client to: A. Add fiber to his diet. B. Take the prescribed dose at bedtime. C. Report incomplete bladder emptying D. Exercise on a regular basis
ANSWER: C Urinary retention is a common anticholinergic side effect of psychotic medications, and the client with benign prostatic hypertrophy would have increased risk for this problem. Adding fiber to one's diet and exercising regularly are measures to counteract another anticholinergic effect, constipation. Depending on the specific medication and how it is prescribed, taking the medication at night may or may not be important. However, it would have nothing to do with urinary retention in this client.
Transurethral resection of the prostate (TURP) is associated with all of the following except: A. Outpatient procedure in most cases B. Most effective long term treatment C. Retrograde ejaculation in 50% of men D. Transfusion rate of 2-4% E. Erectile dysfunction in 2%
Answer: A
When providing discharge teaching for a client with uric acid calculi, the nurse should an instruction to avoid which type of diet? a. Low-calcium b. Low-oxalate c. High-oxalate d. High-purine
Answer: D To control uric acid calculi, the client should follow a low-purine diet, which excludes high-purine foods such as organ meats. A low-calcium diet decreases the risk for oxalate renal calculi. Oxalate is an essential amino acid and must be included in the diet. A low-oxalate diet is used to control calcium or oxalate calculi.
A client had a transurethral prostatectomy for benign prostatic hypertrophy. He's currently being treated with a continuous bladder irrigation and is complaining of an increase in severity of bladder spasms. Which of the interventions should be done first? a. Administer an oral analgesic b. Stop the irrigation and call the physician c. Administer a belladonna and opium suppository as ordered by the physician. d. Check for the presence of clots, and make sure the catheter is draining properly.
Answer: D blood clots and blocked outflow if the urine can increase spasms. The irrigation shouldn't be stopped as long as the catheter is draining because clots will form. A belladonna and opium suppository should be given to relieve spasms but only after assessment of the drainage. Oral analgesics should be given if the spasms are unrelieved by the belladonna and opium suppository.
A male client with a recent history of rectal bleeding is being prepared for a colonoscopy. How should the nurse position the client for this test initially? A. Lying on the right side with legs straight B. Lying on the left side with knees bent C. Prone with the torso elevated D. Bent over with hands touching the floor
answer: B
A 27-year old client, who became paraplegic after a swimming accident, is experiencing autonomic dysreflexia. Which condition is the most common cause of autonomic dysreflexia? A. Upper respiratory infection B. Incontinence C. Bladder distention D. Diarrhea
answer: C Autonomic dysreflexia is a potentially life-threatening complication of spinal cord injury, occurring from obstruction of the urinary system or bowel. Incontinence and diarrhea don't result in obstruction of the urinary system or bowel, respectively. An URI could obstruct the respiratory system, but not the urinary or bowel system.
When providing discharge teaching for a client with uric acid calculi, the nurse should an instruction to avoid which type of diet? A. Low-calcium B. Low-oxalate C. High-oxalate D. High-purine
answer: D To control uric acid calculi, the client should follow a low-purine diet, which excludes high-purine foods such as organ meats. A low-calcium diet decreases the risk for oxalate renal calculi. Oxalate is an essential amino acid and must be included in the diet. A low-oxalate diet is used to control calcium or oxalate calculi.
