Urinary Elimination NCLEX practice questions
Which describes the glomerular filtration rate? 1. The amount of filtrate formed by the kidneys per minute 2. The volume of blood that passes through the kidneys in each cardiac cycle 3. The amount of waste removed by the kidney each minute 4. The amount of urine that collects in the bladder per minute
Answer: 1 Rationales Option 1: The glomerular filtration rate is the amount of filtrate formed by the kidneys per minute. Option 2: The glomerular filtration rate is not the volume of blood filtered in each cardiac cycle. Option 3: The glomerular filtration rate is not the amount of waste removed in a given time. Option 4: The amount of urine that collects in the bladder per minute is not the glomerular filtration rate. [Page reference: 1061] Test Taking Tip: Filtration of blood occurs in the glomeruli.
Which part of the kidney is made up of millions of functional units called nephrons? 1. Cortex 2. Calyx 3. Medulla 4. Renal pelvis
Answer: 1 Rationales Option 1: The cortex is the outer part of the kidney and contains millions of functional units called nephrons. Option 2: The calyx is the central part of the kidney and directs urine into the renal pelvis. Option 3: The medulla is the inner layer of the kidney, made up of collecting tubules. Option 4: The renal pelvis is the innermost layer of the kidney. [Page reference: 1060] Test Taking Tip: The outer layer of the kidney contains millions of functional units called nephrons.
The nurse is discussing ways to treat functional incontinence with a group of older adults in a senior citizens center. Which intervention would be most appropriate for the nurse to include in the presentation? 1. Timed voiding 2. Kegel exercises 3. Straight catheterization 4. Pharmacological treatment
Answer: 1 Rationales Option 1: The nurse would instruct the clients to use the bathroom to urinate every 2 to 3 hours. This alleviates the problem of not being able to get to the bathroom in time. Option 2: The nurse would instruct clients with stress incontinence, not functional incontinence, how to perform Kegel exercises. Option 3: The nurse would encourage a client with a spinal cord injury or neuromuscular disorder, not urinary incontinence, to perform straight catheterization to prevent urinary retention. Option 4: The nurse would discuss pharmacological treatment of urge incontinence with the client and health-care provider. These medications are not appropriate for functional incontinence. [Page reference: 1083]
What should the nurse include in the teaching for a client with an ileal conduit urinary diversion? Select all that apply. 1. Ensure the collection device fits snugly against skin. 2. Empty the ostomy bag frequently. 3. Apply lotion to the area if skin is excoriated. 4. Catheterize the reservoir several times a day. 5. Performing Credé's maneuver to empty the bladder.
Answer: 1, 2 Rationales Option 1: A good snug fit prevents urine from leaking onto the skin. If this happens, it crystallizes and can cause skin irritation. Option 2: The client should be taught to empty the bag when it is about one-third full. This prevents the bag from becoming heavy and separating from the face plate. Option 3: Lotion should not be used on peristomal skin because it can irritate the skin. Option 4: A client with a continent urinary reservoir, not a urinary diversion, would catheterize the reservoir. Option 5: The nurse would instruct the client with a neobladder to perform the Credé's maneuver to empty bladder. This is not applicable for a client with a urinary diversion. [Page reference: 1092]
Which health history information should be obtained before a nurse places an indwelling catheter? Select all that apply. 1. Any allergies 2. History of bladder surgery 3. History of heart disease 4. Any problems with constipation 5. Number of pregnancies
Answer: 1, 2 Rationales Option 1: Allergies to iodine and latex will require alterations to normal indwelling catheter insertion procedure. Option 2: History of bladder disease may require a smaller lumen catheter or alteration in the procedure. Option 3: A history of heart disease is not relevant to catheter insertion. Option 4: Constipation is not relevant to catheter insertion. Option 5: Number of pregnancies is not usually relevant to catheter insertion. [Page reference: 1079-1080]
What should the nurse include in the post-procedure care for a client who underwent a cystoscopy? Select all that apply. 1. Monitor intake and output. 2. Assess color and clarity of urine. 3. Provide only clear liquids. 4. Obtain vital signs every 8 hours. 5. Instruct about the use of contrast dye.
Answer: 1, 2 Rationales Option 1: The nurse would be responsible for monitoring intake and output after a client undergoes a cystoscopy. This ensures adequate urine flow after the procedure. Option 2: The nurse would assess the color and clarity of the urine. This would allow the nurse to detect complications from the procedure such as bleeding. Option 3: The client can resume the diet that was prescribed prior to the procedure. Option 4: Vital signs are obtained more frequently after a cystoscopy due to the use of sedation. Option 5: The nurse would explain about the use of contrast dye when a client has an intravenous pyelogram, not a cystoscopy. [Page reference: 1069]
The parents of a 2-year-old child voice concern to the nurse that they are not able to toilet train the child yet. Which factors should the nurse explain to the parents that affect toilet training? Select all that apply. 1. The child must be able to sense the urge to void. 2. The child must be able to remove his or her clothes. 3. The child must be able to voice the need to urinate. 4. The child must be able to completely wipe from front to back. 5. The child must be able to balance himself or herself on the toilet.
Answer: 1, 2, 3 Rationales Option 1: In order to obtain bladder control, the toddler must be able to sense the urge to urinate. Option 2: The child must be able to remove his or her clothes in order to be toilet trained. Option 3: In order to be toilet trained, the child must be able to verbalize the need to urinate. Option 4: The child does not need to be able to wipe from front to back, as parents and caregivers can help with this. Option 5: The child can be toilet trained using a smaller potty chair until he or she is big enough to sit on a toilet. [Page reference: 1062] Test Taking Tip: The timing of toilet training is highly variable and is influenced by family and culture, as well as the presence of older children to model toileting behavior. In the United States, most parents begin toilet training when their child is between 18 and 36 months of age.
Which factors place female clients at higher risk for urinary tract infections? Select all that apply. 1. Pregnancy 2. Menopause 3. Sexual activity 4. Prostate enlargement 5. Longer urethral length
Answer: 1, 2, 3 Rationales Option 1: Pregnancy can increase a female client's risk for urinary tract infections due to pressure on the bladder and hormonal changes. Option 2: Menopause causes decreased normal flora as well as drying of the vaginal mucosa. These can cause urinary tract infections. Option 3: Perineal pathogens can enter the urinary tract during sexual intercourse, which can cause urinary tract infections. Option 4: Prostate enlargement occurs in men, not women. Option 5: Men have a longer urethral length than women. The shorter urethra places the female at higher risk for urinary tract infections. [Page reference: 1065]
The home health nurse just removed an indwelling urinary catheter from a client per the health-care provider's order. Which instructions should the nurse provide the client? Select all that apply. 1. Report any pain or burning upon urination. 2. Increase oral fluid intake to promote urine production. 3. Contact the health-care provider if unable to urinate 8 hours after catheter removal. 4. Notify the health-care provider after the first void with color and amount of urine. 5. Discard the first urine sample after removing the catheter and then collect the urine in a jug for the next 24 hours.
Answer: 1, 2, 3 Rationales Option 1: The nurse would instruct the client to report any pain or burning upon urination. Indwelling urinary catheters can increase the risk for infections, and the client should report this finding. Option 2: The nurse should instruct the client to drink lots of fluids after the catheter is removed. This will help facilitate urine production. Option 3: The home health nurse should instruct the client to notify the health-care provider if he or she does not urinate 8 hours after the catheter is removed. This may require reinsertion of the catheter if the client is retaining urine. Option 4: The nurse would not instruct the client to notify the health-care provider after the first void. This is an expected outcome and does not warrant health-care provider notification. Option 5: The nurse would instruct a client to discard the first urine sample and collect urine for the next 24 hours if obtaining urine for a 24-hour urine test for protein or creatinine clearance. This is not done after removal of an indwelling urinary catheter. [Page reference: 1116]
The nurse is educating unlicensed nursing assistive personnel (NAP) about recording output for a client. What fluids should the nurse include in the output for accuracy? Select all that apply. 1. Urine 2. Emesis 3. Diarrhea 4. Nasal drainage 5. Intravenous fluids 6. Nasogastric drainage
Answer: 1, 2, 3, 6 Rationales Option 1: Urine is a body fluid that should be recorded in the client's output. Option 2: Body fluids that should be recorded in the output include any emesis the client has. Option 3: Diarrhea needs to be charted in the output in the client's medical record. Option 4: Nasal drainage is not calculated, nor is it recorded in the output. Option 5: Intravenous fluids would be recorded under the intake section, not the output. Option 6: Nasogastric drainage is recorded in the output. [Page reference: 1070]
Which structures are contained within a nephron? Select all that apply. 1. Collecting duct 2. Bowman's capsule 3. Ureters 4. Renal cortex 5. Filtrating tubules
Answer: 1, 2, 5 Rationales Option 1: A collecting duct is where filtrate is collected. Option 2: A Bowman's capsule is a double-walled hollow capsule that encloses a knotted ball of capillaries. Option 3: Ureters extend from the kidneys to the bladder. Option 4: The renal cortex is the outer layer of the kidney that contains the nephrons. Option 5: Filtrating tubules provide additional filtration of wastes. [Page reference: 1060] Test Taking Tip: The nephron is the basic structural and functional unit of the kidney.
Which actions occur to blood as it moves through the peritubular capillaries? Select all that apply. 1. Removes ammonia from blood 2. Hydrogen ions secreted to help maintain normal blood pH 3. Antidiuretic hormone produced 4. Aldosterone secreted 5. Removes creatinine from the blood
Answer: 1, 2, 5 Rationales Option 1: As blood moves through peritubular capillaries, waste products, including ammonia, are removed. Option 2: Hydrogen ions are secreted by the peritubular capillaries to normalize blood pH. Option 3: Antidiuretic hormone is produced by the posterior pituitary gland. Option 4: Aldosterone is secreted by the posterior pituitary gland. Option 5: Waste products are removed from blood as it moves through the peritubular capillaries. [Page reference: 1061]
Which are goals of nursing care for a client with an indwelling urinary catheter? Select all that apply. 1. Prevent infection. 2. Maintain skin integrity. 3. Prevent the client from ambulating. 4. Keep the catheter in as long as possible. 5. Maintain the free flow of urine.
Answer: 1, 2, 5 Rationales Option 1: Indwelling urinary catheters can be a source of infection of the urinary tract. Option 2: Skin integrity in the area of the catheter is at risk when a catheter is in place. Option 3: A client with a catheter should be encouraged to ambulate if possible. Option 4: A catheter should be removed as soon as possible to prevent infection and return urine function to normal. Option 5: The nurse should take care to avoid kinks or pressure on the catheter line. [Page reference: 1080]
Which physiological factors can place an 83-year-old client at risk for acute kidney injury? Select all that apply. 1. Decline in glomerular function 2. Loss of urinary sphincter control 3. Arteriosclerotic blood vessel changes 4. Decreased abdominal muscle control 5. Consumption of large quantities of caffeine
Answer: 1, 3 Rationales Option 1: By the time a client is 80-years-old, only about two-thirds of the nephrons function. This places the client at risk for acute kidney injury. Option 2: Loss of urinary sphincter control leads to urinary incontinence, not acute kidney injury. Option 3: Arteriosclerosis occurs with age and this decreases blood flow to the kidneys. Option 4: Clients, especially females, are at higher risk for urinary incontinence when abdominal muscle control decreases. This does not cause acute kidney injury. Option 5: Caffeine is a diuretic and increases urine production. This does not place the client at risk for acute kidney injury. [Page reference: 1063]
Which interventions should the nurse instruct the client to perform to decrease the incidence of urinary incontinence? Select all that apply. 1. Limit caffeine intake to one cup of coffee a day. 2. Limit the intake of fluids. 3. Stop smoking. 4. Lose weight. 5. Increase the use of artificial sweeteners.
Answer: 1, 3, 4 Rationales Option 1: Caffeine is an irritant to the bladder mucosa. Therefore, it should be limited to < 100 mg daily (about one cup of coffee or two 12-ounce cans of cola). Option 2: The nurse would not instruct the client to limit fluid intake. This can lead to acute kidney injury, infection, and dehydration. Option 3: Smoking has been linked to urinary incontinence as well as other health problems. Option 4: If the client is overweight, weight loss has been found to decrease the incidence of urinary incontinence. Option 5: The client should decrease the use of artificial sweeteners, as these can irritate the bladder mucosa and cause urinary incontinence. [Page reference: 1084]
The nurse is providing discharge teaching for a client who will be taking a loop diuretic. What should the nurse include in the teaching? Select all that apply. 1. Change positions slowly. 2. Stay out of direct sunlight. 3. Report any muscle weakness. 4. Notify the health-care provider of any rash. 5. Signs and symptoms of high potassium levels.
Answer: 1, 3, 4 Rationales Option 1: Diuretics have a side effect of hypotension and dizziness. Therefore, the nurse should teach the client to change positions slowly. Option 2: The nurse would instruct the client who is taking a thiazide diuretic, not a loop diuretic, to stay out of the direct sunlight. Option 3: The nurse would instruct the client to report any muscle weakness, as this can be a major complication from diuretic use. Option 4: A rash indicates a possible allergic reaction and this should be reported. Option 5: The nurse would instruct the client about the signs and symptoms of low potassium levels as this is a side effect of loop diuretics. [Page reference: 1063]
A nurse is assessing a urostomy on a client. She should be most concerned about which findings? Select all that apply. 1. Sloughing of skin 2. Moisture 3. Skin breakdown 4. Encrustation 5. Red in color
Answer: 1, 3, 4 Rationales Option 1: Sloughing of skin could be the result of severe skin irritation. Option 2: A normal urostomy site is moist and shiny. Option 3: Skin breakdown can occur if urine is left on the skin for a period of time. Option 4: Encrustation is a risk for a localized infection in a urostomy. Option 5: A normal urostomy is red in color. [Page reference: 1092] Test Taking Tip: A healthy stoma is deep pink to brick red, moist, and shiny with no encrustation, maceration, or excoriation in the area. Urine is acidic but becomes alkaline when in contact with skin. This can create skin breakdown that is at risk for infection.
What clinical manifestations might a nurse expect to see if a client has impaired renal function? Select all that apply. 1. High blood pressure 2. Altered mental status 3. Increased urine production 4. Fluid retention 5. Decreased heart rate
Answer: 1, 3, 4 Rationales Option 1: When the body is unable to rid itself of sodium, fluid is retained and blood pressure increases. Option 2: When ammonia levels increase, lethargy and confusion occur as a result. Option 3: Urine production will not increase with impaired renal function. Option 4: When filtration is impaired, the body retains fluid. Option 5: Heart rate is likely to increase as a result of increased cardiac workload from fluid volume increase. [Page reference: 1060] Test Taking Tip: When renal function is impaired, the body is not able to maintain fluid balance.
The nurse just finished inserting an indwelling urinary catheter into a client and is sitting down to document the procedure. Which information should the nurse include in the medical record? Select all that apply. 1. Catheter size 2. Provision of privacy 3. Date and time of insertion 4. Projected date of removal 5. Amount of saline in balloon 6. Color, clarity, and amount of urine return
Answer: 1, 3, 5, 6 Rationales Option 1: The nurse should document the size of the catheter inserted. This allows others to know the size in case of complications. Option 2: The nurse does not need to document in the medical record that privacy was provided to the client during the insertion. Option 3: The nurse must document he date and time of the catheter insertion. This allows facilities to monitor the length of time the catheter is in place and to monitor for infection. Option 4: The nurse need not document the projected date of removal, as this is based on the health-care provider's orders. Option 5: The nurse would document the amount of saline inserted into the balloon. This provides information for the nurse when removing the catheter. Option 6: The nurse should document the amount of urine obtained after insertion as well as the color and clarity of the urine. [Page reference: 1116]
Which are urinary symptoms that may occur as a result of the aging process? Select all that apply. 1. Leakage of urine 2. Decreased frequency of urination 3. Decreased volume of urine 4. Nocturnal frequency of urine 5. Bladder infections
Answer: 1, 4, 5 Rationales Option 1: Leakage of urine related to loss of pelvic muscle tone can occur. Option 2: Decreased frequency of urination is not associated with aging. Option 3: Decreased volume of urine produced is not associated with aging. Option 4: Nocturnal frequency of urine may occur as a result of incomplete bladder emptying. Option 5: Bladder infections can occur as a result of incomplete bladder emptying. [Page reference: 1063]
A urine specimen is obtained by a client cleaning the exterior meatus, then beginning to void, then collecting the urine sample midstream. Which type of specimen does this describe? 1. Freshly voided specimen 2. Clean-catch specimen 3. Sterile urine specimen 4. 24-hour specimen
Answer: 2 Rationales Option 1: A freshly voided specimen is collected without using any specific technique. Option 2: A clean-catch urine specimen is collected midstream to avoid contamination from the outer meatus. Option 3: A sterile urine specimen is usually obtained through a straight catheter, with no contact outside the body. Option 4: A 24-hour urine specimen is a collection of all urine voided over 24 hours. [Page reference: 1072]
A nurse is caring for an elderly client who has nearly fallen twice while getting out of bed to go to the bathroom. The nurse has instructed the client not to get up without assistance. The client tells the nurse about feeling a need to get to the bathroom when the urge to void occurs and feeling a need to rush. Which strategy should the nurse utilize to minimize the client's risk of falling? 1. Obtain an order for an indwelling catheter. 2. Check on the client every 2 hours and offer toileting assistance. 3. Require that a family member stay with the client. 4. Obtain an order for restraints to prevent injury.
Answer: 2 Rationales Option 1: An indwelling catheter has a risk of injury or infection. Option 2: Offering frequent toileting can help the client with voiding before the bladder is full. Option 3: Requiring a family member to stay may not be possible, and it may not decrease the risk of falling. Option 4: Restraints should only be used as a last resort, and never to prevent falling. [Page reference: 1063] Test Taking Tip: When providing care for clients, remember that urinary function diminishes with age. Even ambulatory clients may have difficulty getting to the bathroom in a timely manner.
Which condition in older men can result in impaired flow of urine from the bladder into the urethra? 1. Renal calculi 2. Prostatic hypertrophy 3. Cardiovascular disorders 4. Stroke
Answer: 2 Rationales Option 1: Renal calculi can impair urinary elimination, but the mechanism is not from the bladder to the urethra. Option 2: Prostatic hypertrophy is an enlarged prostate, and it can impair flow of urine out of the bladder. Option 3: Cardiovascular disorders can interfere with normal renal function, but the mechanism is not the outflow of urine from the bladder. Option 4: A stroke can lead to urinary incontinence, not impaired urine outflow. [Page reference: 1064] Test Taking Tip: In older men, excessive growth of the prostate can impair flow of urine from the bladder to the urethra. This condition can require surgical intervention.
What anatomical feature makes women more prone to urinary tract infections than men? 1. Increased width of the pelvic bones 2. Proximity of the urethra to the vagina and anus 3. Larger bladder 4. Decreased length of the ureters
Answer: 2 Rationales Option 1: Width of pelvic bones does not contribute to increased urinary tract infections. Option 2: The proximity of the urethra to the vagina and anus and exposure to bacteria make women more prone to urinary tract infections than men. Option 3: Women do not have a larger bladder than men. Option 4: Ureters are not longer in women than in men. [Page reference: 1062] Test Taking Tip: The urethra carries urine from the bladder to outside of the body. .
The nurse is reviewing the laboratory data for a client admitted with acute kidney injury. Which values would the nurse expect to see elevated? Select all that apply. 1. Sodium 2. Creatinine 3. Red blood cells (RBC) 4. Blood urea nitrogen (BUN) 5. Glomerular filtration rate (GFR)
Answer: 2, 4 Rationales Option 1: The sodium level is decreased in acute kidney injury due to excess fluid retention. Option 2: The creatinine level would be increased in a client with acute kidney injury, as the kidney cannot filter nitrogenous waste products. Option 3: The RBC would be decreased. The kidneys produce erythropoietin, which is essential for making red blood cells. If the client has acute kidney injury, erythropoietin production decreases. Option 4: The BUN is increased due to a buildup of nitrogenous waste products that happens in acute kidney injury. Option 5: The GFR decreases in acute kidney injury, as the kidney cannot adequately filter the blood. [Page reference: 1074]
Which functions of the kidney are considered secondary functions? Select all that apply. 1. Acid-base balance 2. Renin production 3. Water reabsorption 4. Vitamin D activation 5. Erythropoietin secretion
Answer: 2, 4, 5 Rationales Option 1: Acid-base balance is a primary function of the kidney. It does this by regulating hydrogen ion excretion. Option 2: Renin is excreted by the kidneys in response to hypotension. It is a secondary function of the kidneys. Option 3: Water reabsorption is a primary kidney function. Option 4: The secondary functions of the kidneys include the activation of vitamin D. Option 5: A secondary function of the kidneys is to secrete erythropoietin in response to hypoxia. [Page reference: 1060]
A nurse is placing an indwelling catheter in an obese female client and realizes that the catheter is in the vagina rather than the urinary meatus. Which action should the nurse take? 1. Remove the catheter from the vagina and again try to place the catheter. 2. Adjust the client's position or lighting and attempt again with the same catheter. 3. Discard the catheter, adjust the client's position and lighting, and try again with a new catheter. 4. Discard the catheter and ask another nurse to try to place the catheter.
Answer: 3 Rationales Option 1: Catheter insertion is a sterile procedure, and once the catheter is contaminated, it must be discarded. Option 2: It is appropriate to adjust the client's position, but not to attempt again with the same catheter. Option 3: Once the catheter is contaminated, it cannot be used again for additional placement attempts. Option 4: It is not inappropriate to ask for assistance; rather, the nurse should attempt another placement. [Page reference: 1110] Test Taking Tip: An indwelling catheter is placed using sterile technique. The catheter itself is sterile and is considered contaminated if it touches anything outside of the inner urinary meatus.
What is the purpose of using a drape when inserting a catheter? 1. Reduces the risk of infection 2. Improves lighting for the procedure 3. Provides privacy for the client 4. Helps regulate temperature
Answer: 3 Rationales Option 1: Draping provides little protection from infection. Option 2: Draping does not improve lighting during the insertion of a catheter. Option 3: Draping provides comfort and privacy for the client. Option 4: Draping does little to regulate temperature. [Page reference: 1101]
Which is an advantage of intermittent catheterization over indwelling catheters? 1. Convenience to the client 2. Decreased risk of infection 3. Can be removed immediately and client can void normally 4. Convenient for the nurse
Answer: 3 Rationales Option 1: Intermittent catheterization is not more convenient to the client, as it may be a repeat procedure. Option 2: There is a risk of infection with every catheter insertion. Option 3: An intermittent catheter does not remain in place and the client can resume voiding. Option 4: Intermittent catheterization is not more convenient for the caregiver. [Page reference: 1077] Test Taking Tip: An intermittent, or straight catheter, is a small lumen catheter that is inserted to drain the bladder.
A client reports severe pain in the pubic area and the nurse determines the client has acute urinary retention. The client reports never experiencing this before. Which new medication may be the cause? 1. Lisinopril 2. Ibuprofen 3. Fexofenadine 4. Metoprolol
Answer: 3 Rationales Option 1: Lisinopril is an ACE inhibitor. It does not cause urinary retention. Option 2: Ibuprofen is a nonsteroidal anti-inflammatory medication used to treat pain. This medication does not lead to urinary retention. Option 3: Fexofenadine is an antihistamine that has a side effect of urinary retention. Option 4: Metoprolol is a beta blocker used to treat hypertension and dysrhythmias. It does not have a side effect of urinary retention. [Page reference: 1064] Test Taking Tip: Urinary retention is the inability to completely empty the bladder, and it can be caused by some medications.
When inserting an indwelling catheter, which level of asepsis is used? 1. Medical asepsis 2. Disinfection 3. Surgical asepsis 4. Low level asepsis
Answer: 3 Rationales Option 1: Medical asepsis, or clean technique, is not used during catheter insertion. Option 2: Disinfection refers to removal of pathogens from a nonliving surface. Option 3: Surgical asepsis, or sterile technique, is used for catheter insertion. Option 4: Low level disinfection is only used on inanimate objects. [Page reference: 1110]
Which laboratory test should be performed prior to a client undergoing a renal biopsy? 1. Urinalysis 2. Blood glucose 3. Coagulation studies 4. Hepatic function panel
Answer: 3 Rationales Option 1: The client does not need to have a urinalysis prior to undergoing a renal biopsy. A urinalysis assesses specific gravity as well as the presence of glucose and blood cells. Option 2: The client should not need to have a blood glucose level obtained prior to having a renal biopsy unless the client has diabetes mellitus. Option 3: The nurse should make sure the client has undergone coagulation studies, such as a protime with INR and a partial thromboplastin time, prior to undergoing a renal biopsy. Option 4: Liver function does not need to be assessed prior to undergoing a renal biopsy. Therefore, the nurse would not expect the hepatic function panel to be obtained. [Page reference: 1070]
The nurse calculates urinary output for a client admitted with dehydration and determines the client's output is 800 mL/day. Which nursing intervention is most appropriate for the nurse to perform first? 1. Notify the health-care provider. 2. Document the finding as normal. 3. Assess the urine color and clarity. 4. Insert an indwelling urinary catheter.
Answer: 3 Rationales Option 1: The normal daily urine output should be a minimum of 1200 mL. This client is at risk for urinary dysfunction due to low output. However, the nurse needs to obtain more information prior to contacting the health-care provider. Option 2: The nurse should not document the finding as normal, as there is a problem with the urinary output. Option 3: The nurse needs more information prior to notifying the health-care provider. Therefore, the nurse should assess the color and clarity of the urine first. Option 4: The nurse would not insert an indwelling urinary catheter without first obtaining an order from the health-care provider. [Page reference: 1073] Test Taking Tip: Normal daily urine output is a minimum of 1200 mL.
How would the nurse assess for costovertebral angle tenderness? 1. Inspect the urinary meatus. 2. Auscultate over the abdominal aorta. 3. Percuss between the 12th rib and spine. 4. Palpate in the pubic area over the bladder.
Answer: 3 Rationales Option 1: The nurse would inspect the urinary meatus prior to inserting an indwelling urinary catheter. This is not done prior to determining costovertebral angle tenderness. Option 2: The nurse would auscultate over the abdominal aorta to determine the presence of a bruit. This is not assessing for costovertebral angle tenderness. Option 3: The nurse would percuss the area between the 12th rib and spine on both sides to determine the presence of costovertebral angle tenderness. Option 4: The nurse would palpate in the pubic area over the bladder to determine bladder distention; not costovertebral angle tenderness. [Page reference: 1068]
Which ion controls acid-base balance? 1. Sodium 2. Oxygen 3. Hydrogen 4. Potassium
Answer: 3 Rationales Option 1: The presence of sodium controls water reabsorption, as water follows sodium. It does not control acid-base balance. Option 2: A lack of oxygen stimulates the production of erythropoietin. It does not affect acid-base balance. Option 3: The presence of hydrogen controls acid-base balance. Too much hydrogen causes acidosis; too little causes alkalosis. Option 4: Potassium imbalances cause cardiac dysrhythmias. It is not related to acid-base balance. [Page reference: 1061]
Which is a normal specific gravity for urine? 1. 0.12 2. 1.30 3. 1.02 4. 13.0
Answer: 3 Rationales Option 1: This specific gravity is well below normal. Option 2: This specific gravity is above normal. Option 3: Normal specific gravity is 1.002 to 1.030. Option 4: This specific gravity is well above normal. [Page reference: 1062] Test Taking Tip: Specific gravity is the measure of dissolved solutes in a solution.
A client presents to the emergency department with nausea and vomiting for 2 days. The client states he or she has not urinated at all for the past 8 hours. Which is the most likely cause of his lack of urine output? 1. Impaired renal function 2. Renal calculi 3. Dehydration 4. Prostatic hypertrophy
Answer: 3 Rationales Option 1: With a 2-day history of vomiting, renal impairment is not the most likely cause of low output. Option 2: Renal calculi are not the likely cause of decreased urine output. Option 3: The history of nausea and vomiting indicate that the client is likely to have a decreased fluid intake. Option 4: Prostatic hypertrophy is not the most likely cause of decreased urine output. [Page reference: 1062] Test Taking Tip: If a client has a low urine output, it might be assumed that the client has renal impairment. However, the nurse should look for other contributing causes.
Which piece of information is most important for the nurse to obtain prior to removing an indwelling urinary catheter? 1. Date of insertion 2. Type of catheter material 3. Amount of saline in balloon 4. Allergy to betadine or shellfish
Answer: 3 Rationales Option 1: The date of insertion is not the most important aspect to know prior to the removal of an indwelling urinary catheter. The nurse may need to know this prior to changing the catheter. Option 2: The nurse would need to pay attention to the type of material used prior to insertion, especially if the client has a latex allergy. However, this is not needed prior to removal. Option 3: The nurse would need to know the amount of saline inserted into the balloon prior to removing the catheter. This allows the nurse to use the correct syringe size and to ensure the nurse removes all of the saline before pulling the catheter out. Option 4: The nurse would need to know allergies to betadine and shellfish prior to inserting the catheter as betadine is used in the prep. This is not necessary to know prior to removal. [Page reference: 1111]
Place the anatomical structures in the order in which blood is filtered. 1. Urine is carried from the kidneys to the bladder through the ureters. 2. The urinary meatus is the way in which urine leaves the body. 3. The kidneys contain nephrons, which perform filtration of blood and forms urine. 4. Urine from the ureters is stored in the bladder.
Answer: 3,1,4,2 Blood is taken into the nephrons, which are in the renal cortex of the kidney. Blood is filtered and urine is formed. Urine is transported from the kidneys to the bladder through the ureters. Urine is then stored in the bladder until it is expelled from the body through the urinary meatus. [Page reference: 1060-1062]
The nurse is preparing to remove an indwelling urinary catheter from a client who underwent a prostatectomy a week ago. Which size syringe would be most appropriate for the nurse to use to deflate the retention balloon? 1. 3 mL 2. 5 mL 3. 10 mL 4. 30 mL
Answer: 4 Rationales Option 1: A 3-mL syringe is too small for removing the water from the retention balloon for an adult. It is the correct size for a child. Option 2: A 5-mL syringe would be used to remove an indwelling urinary catheter from an adult client who did not have a urological procedure performed. Option 3: Sometimes a 10-mL syringe is used to inflate a retention balloon in an adult client who uses an indwelling urinary catheter on a long-term basis. However, this is a catheter used after a urological procedure. Option 4: A urologist would insert an indwelling urinary catheter with a 30-mL retention balloon in a client who underwent prostate surgery. This would prevent the catheter from being pulled out. [Page reference: 1078]
The nurse is caring for a client with acute kidney injury and reviews the medical record for new orders. Which order given by the health-care provider should the nurse question? 1. Cystoscopy 2. Cystometry 3. Renal biopsy 4. Intravenous pyelogram
Answer: 4 Rationales Option 1: A cystoscopy is not contraindicated for a client with acute kidney injury. This procedure could be used to remove stones that may be causing the acute kidney injury. Option 2: Cystometry is used to measure the amount of urine in the bladder as well as the amount of pressure in the bladder. This test would be allowed for this client. Option 3: A renal biopsy is a procedure that could be used to determine the cause of acute kidney injury. It is not contraindicated. Option 4: An intravenous pyelogram is contraindicated in a client with acute kidney injury, as the intravenous dye is nephrotoxic and can worsen the kidney injury. [Page reference: 1069]
What is the term for the amount of blood that is filtered in a minute? 1. Creatinine 2. Ammonia 3. Blood urea nitrogen 4. Glomerular filtration rate
Answer: 4 Rationales Option 1: Creatinine is a nitrogenous waste product that is excreted by the kidneys. Option 2: Ammonia is a waste product of protein metabolism. It is not the term for the amount of blood filtered in a minute. Option 3: Blood urea nitrogen is a nitrogenous waste product. It is not the term for the amount of blood filtered in a minute. Option 4: The glomerular filtration rate measures the amount of blood that is filtered through the glomerulus in a minute. [Page reference: 1061]
A client presents to the emergency room with vomiting and diarrhea. The client is dehydrated. Which hormone does the nurse expect to be secreted by the posterior pituitary gland to reduce water loss? 1. Renin 2. Aldosterone 3. Erythropoietin 4. Antidiuretic hormone (ADH)
Answer: 4 Rationales Option 1: Renin is secreted by the kidneys to increase blood pressure. Option 2: While aldosterone does promote water retention, it is produced by the adrenal cortex, not the posterior pituitary gland. Option 3: Erythropoietin is a hormone produced by the kidneys to increase red blood cell production. Option 4: ADH is a hormone manufactured by the posterior pituitary gland in response to water loss. [Page reference: 1061]
The nurse has an order to obtain a urine specimen for a culture and sensitivity test from a client with an indwelling urinary catheter. Which procedure is accurate for obtaining the specimen? 1. Obtaining the specimen from the drainage bag 2. Disconnecting the tubing and obtaining the specimen 3. Inserting a new indwelling urinary catheter to obtain a sterile urine specimen 4. Clamping the tubing and withdrawing a fresh specimen from the tubing aseptically
Answer: 4 Rationales Option 1: The nurse would not obtain the sample from the drainage bag, as it may be several hours old. Option 2: The nurse should not disconnect the seal between the drainage bag and the catheter. This opens the tubing and places the client at risk for infection. Option 3: The nurse would not need to insert a new indwelling urinary catheter because this is not needed. Option 4: The nurse would clamp the tubing and withdraw a fresh specimen from the tubing aseptically. This ensures the specimen is sterile and not contaminated. [Page reference: 1081]
A nurse is inserting an indwelling catheter into a client. She begins to inflate the balloon, she feels resistance, and the client complains of discomfort. Which action should the nurse take? 1. Remove the catheter and discard it. 2. Notify the physician and document that the client refused a catheter. 3. Deflate the balloon and advance the catheter about an inch before attempting again. 4. Leave the catheter in place without inflating the balloon.
Answer: 4 Rationales Option 1: This is not the appropriate action to take in this situation. Option 2: This is not the appropriate action to take in this situation. Option 3: The balloon is likely in the urethra; advancing it will place it in the bladder correctly. Option 4: The catheter will not stay in place without the balloon being inflated. [Page reference: 1109] Test Taking Tip: If a client complains of pain, or if resistance is met when the balloon is inflated, the balloon is likely in the urethra.