CHAPTER 13- Renal:Urinary System

Question 1

The most common bacteria involved in urinary tract infections is:

1. Klebsiella.
2. Escherichia coli.
3. Clostridium difficile.
4. Staphylococcus.

Answer 1

2. Escherichia coli.

Escherichia coli accounts for 85% of all infections.

Question 2

A 25-year-old female comes to the outpatient clinic complaining of suprapubic pressure and burning with urination for the past two days. She denies having any chills but states that she may have had a fever yesterday. The next step will be:

1. Obtain a urine dipstick.
2. Get a urine culture and sensitivity.
3. Ask about previous infections.
4. Refer the patient to a urologist.

Answer 2

3. Ask about previous infections.

The next step in assessing/treating this patient will depend on whether or not this urinary tract infection is recurrent or a first occurrence.

Question 3

Referring to the above case, the patient states that she has not had any prior urinary tract infections. The next step will be to:

1. Obtain a urine dipstick.
2. Get a urine culture and sensitivity.
3. Ascertain any drug allergies.
4. Refer the patient to a urologist.

Answer 3

2. Get a urine culture and sensitivity.

In an uncomplicated or non-recurring urinary tract infection, a urinalysis (dipstick or microscopic) can adequately identify urinary tract infections. A urine culture and sensitivity should be performed in the following cases: (1) any patient with a first febrile infection; (2) a recurrent infection with or without fever (more than one per year); (3) a urinary calculi; and (4) a congenital defect.

Question 4

A mother brings in her 4-month-old boy and states that the baby has had a low-grade fever, been more irritable than usual, and has had foul-smelling urine. What is the most appropriate next step?

1. Obtain a urine dipstick.
2. Get a urine culture and sensitivity.
3. Immediately start the patient on an antibiotic.
4. Refer the patient to a urologist.

Answer 4

4. Refer the patient to a urologist.

Structural defects are the most common cause of urinary tract infections in infant males.

Question 5

A young female visits your clinic and complains of burning with urination. She states that she had these same symptoms about six months ago and was diagnosed with a urinary tract infection. She reports that a 3-day course of antibiotic was effective. Upon further questioning, it is uncovered that she has just become sexually active. Patient education should include all of the following EXCEPT:

1. Voiding after intercourse may prevent recurrent UTI.
2. Using a spermicide may increase your risk of UTI.
3. Drinking 6 ounces of cranberry juice daily may prevent future UTI.
4. She could use prophylactic antibiotic if she develops recurrent UTI.

Answer 5

3. Drinking 6 ounces of cranberry juice daily may prevent future UTI.

There is no current evidence supporting the use of cranberry products. Adequate fluid intake (water) is recommended to remain well hydrated.

Question 6

A 19-year-old boy comes in for a follow-up of exudative tonsillitis with a streptococcus positive throat culture. He states that his throat feels much better but this morning his urine had a pink tinge and was very foamy. What does the FNP suspect is happening with this patient?

1. Nephrolithiasis
2. Hydronephrosis
3. UTI
4. Glomerulonephritis

Answer 6

4. Glomerulonephritis

Foamy and pink-tinged urine can signify proteinuria and hematuria, respectively. The most common complication of streptococcus is glomerulonephritis.

Question 7

What are the four criteria in making a diagnosis of nephrotic syndrome?

1. Proteinuria, hypoalbuminemia, edema, dyslipidemia
2. Proteinuria, hyperalbuminemia, edema, dyslipidemia
3. Proteinuria, hypoalbuminemia, edema, hyperthyroidism
4. Proteinuria, hyperalbuminemia, edema, hypothyroidism

Answer 7

1. Proteinuria, hypoalbuminemia, edema, dyslipidemia

The four criteria in diagnosing nephrotic syndrome are: proteinuria (>3g/day), hypoalbuminemia, hypercholesterolemia/hypertriglyceridemia, and edema. Nephrotic syndrome increases one risk of developing hypothyroidism.

Question 8

In reviewing a 42-year-old female’s bloodwork, the results indicate a diagnosis of nephrotic syndrome. Patient education should include all of the following EXCEPT:

1. This condition increases your risk of infection.
2. This condition increases your likelihood of clot formation.
3. She needs to monitor her sodium intake.
4. She needs to decrease her protein intake.

Answer 8

4. She needs to decrease her protein intake.

Proteinuria is often treated with the administration of angiotensin converting enzyme (ACE) or angiotensin-receptor blocker (ARB) medications and close monitoring of serum potassium and creatinine levels. A normal protein diet may be consumed.

Question 9

The most common stone composition of nephrolithiasis is:

1. Struvite (magnesium, ammonium, and phosphate).
2. Calcium oxalate.
3. Cysteine.
4. Uric acid.

Answer 9

2. Calcium oxalate.

Calcium oxalate makes up about 70–80% of kidney stones, followed by struvite (15%), uric acid (7%), and cysteine (1%).

Question 10

A 25-year-old female comes to the office complaining of right-sided abdominal pain that has radiated to the groin area for the last 2 days. She has felt nauseated and has had a decreased appetite. The differential diagnosis will include all of the following EXCEPT:

1. Ectopic pregnancy.
2. Pyelonephritis.
3. Constipation.
4. Acute intestinal obstruction.

Answer 10

3. Constipation.

In the case presentation, the following conditions need to be ruled out: hydronephrosis, glomerular nephritis, UTI/pyelonephritis, dysmenorrhea, acute intestinal obstruction, acute mesenteric ischemia, herpes zoster, and ectopic pregnancy in females.

Question 11

In educating a female patient with nephrolithiasis, the FNP reviews with the patient all of the following EXCEPT:

1. Adequate hydration may decrease her risk of reoccurrence.
2. How to strain her urine in order to analyze the type of stone.
3. Advising her to increase her intake of cranberry juice or take cranberry supplements.
4. Explaining that she has a 50% increased risk of reoccurrence over the next 5 years.

Answer 11

3. Advising her to increase her intake of cranberry juice or take cranberry supplements.

The evidence for recommending cranberry juice/supplement is inconclusive. Increased water intake is advised to minimize stone formation.

Question 12

The FNP diagnoses a UTI in a 33-year-old female who provides a history of dysuria and frequency × 48 hours, and a urine dipstick that was positive for nitrites. She admits to having had two UTIs in the last 6 months. The FNP initiates antibiotic therapy with ciprofloxacin. The patient calls the FNP two days later to state that she has developed a fever. What is the next step?

1. Change her antibiotic.
2. Have her return and obtain a urinalysis and a urine culture and sensitivity.
3. Refer to urology
4. Tell her to increase hydration and take Tylenol (acetaminophen) for fever.

Answer 12

3. Refer to urology

Results of a urine culture and sensitivity will take approximately 48 hrs to return. The patient can rapidly deteriorate during this time. It is best to have her seen by a urologist immediately.

Question 13

A 44-year-old male is diagnosed with nephrolithiasis by ultrasonography. He is discharged with a strainer and a follow-up appointment with a urologist two weeks later. Patient education includes all of the following EXCEPT:

1. Use the strainer when you urinate and bring the stones, if any, to the urologist for analysis.
2. If fever develops, take Tylenol (acetaminophen) 650 mg q4h (4 hours a day) prn (pro re nata).
3. Tell him to eat foods rich in calcium.
4. Drink plenty of fluids.

Answer 13

2. If fever develops, take Tylenol (acetaminophen) 650 mg q4h (4 hours a day) prn (pro re nata).

Fever can indicate pyelonephritis. If untreated, pyelonephritis can lead to kidney damage and/or renal failure.

Question 14

While reviewing the laboratory results of a 32-year-old man who came to the office for a complete physical exam two days prior, it is noted that his blood urea nitrogen and creatinine levels are as follows: 19 mg/dL (normal 7–18 mg/dL) and 1.4 mg/dL (normal 0.6–1.2 mg/dL). Previous results from six months prior were within normal limits. What’s the next step?

1. Tell the patient to increase consumption of fluids.
2. Check a urinalysis.
3. Repeat the bloodwork and assess medication intake.
4. Tell the patient “Not to worry.” These elevations are minimal and you will recheck them in six months at the next follow-up visit.

Answer 14

3. Repeat the bloodwork and assess medication intake.

Repeat the test to ensure that a laboratory error did not occur. Intake of non-steroidal anti-inflammatory medications needs to be ruled out in the acute onset of kidney disease.

Question 15

A patient complains of possible blood in her urine. A urine dipstick is positive for hemoglobin and leukocytes. A urinalysis, urine culture, and sensitivity and renal ultrasound are ordered to rule out all of the following EXCEPT:

1. Nephrotic syndrome.
2. Nephrolithiasis.
3. Glomerulonephritis.
4. UTI.

Answer 15

1. Nephrotic syndrome.

All but nephrotic syndrome may present with hematuria.

Question 16

A 28-year-old woman who is 7 months pregnant comes to the urgent care. She states that she is on the third day of Macrobid (nitrofurantoin) and says she still has some dysuria and had a fever last night. The next step is:

1. Change her antibiotic and obtain a urine culture.
2. Start patient on some IV fluids and refer to urology.
3. Tell her to continue her medication; her symptoms will resolve eventually.
4. Start her on pyridium.

Answer 16

2. Start patient on some IV fluids and refer to urology.

Prompt treatment of UTI is of utmost importance when pregnant. UTI often escalates to pyrlonephritis in pregnancy and complications can ensue.

Question 17

A 44-year-old African American female comes to the office to discuss symptoms of stress incontinence that she has been having for the last three months. The FNP tells her that:

1. Her symptoms may resolve if she loses some weight.
2. Her race is associated with a higher prevalence of incontinence.
3. Stress incontinence is usually seen in older females, while urge incontinence is more prevalent in younger-aged females.
4. Fluid intake has no impact on her symptoms.

Answer 17

1. Her symptoms may resolve if she loses some weight.

Stress incontinence is more prevalent in the obese. Caucasian females have a higher incidence of stress incontinence than African Americans. Adequate hydration is important; however, fluids should be limited at bedtime. Caffeine and alcohol may worsen symptoms. Stress incontinence is more prevalent in younger females, while urge incontinence is more frequently seen in older females.

Question 18

The FNP diagnoses a 42-year-old male with glomerulonephritis. Which potential complications will be monitored?

1. Bradycardia
2. Hypertension
3. Decreased cardiac output
4. Hypotension

Answer 18

2. Hypertension

Signs and symptoms of glomerulonephritis include: hypertension, tachycardia, edema, decreased urine output (oliguria), lethargy, and other signs of fluid overload. Pre-renal causes of acute renal failure are characterized by signs of hypotension.

Question 19

The FNP sees a 52-year-old man who needs an intravenous pyelogram (IVP). What do you need to assess prior to the procedure?

1. Ability of patient to pass urine
2. Ability of patient to tolerate PO fluids
3. Current medication list.
4. That the patient is ambulatory.

Answer 19

3. Current medication list.

Assessing the patient’s current medication list for nephrotoxic medications such as non-steroidal anti-inflammatory drugs and metformin is important to avoid kidney injury. If patient cannot tolerate PO fluids, IV hydration will be maintained.

Question 20

Referring to the preceding case, what is the patient encouraged to do after he returns from his procedure?

1. Increase fluid intake.
2. Increase ambulation.
3. Increase frequent urination.
4. Continue bed rest.

Answer 20

1. Increase fluid intake.

The dye utilized to perform the IVP is nephrotoxic. Encouraging an increase in PO fluid intake will aid in clearing the drug from the body.

Question 21

A 26-year-old female is being treated for cystitis. She informs the FNP that this is the third reoccurrence in almost a year. The FNP proceeds to ask her about her fluid intake. Which of the following would the FNP encourage her to stop drinking?

1. Fruit juice
2. Tea
3. Water
4. Lemonade

Answer 21

2. Tea

Caffeine and alcohol are known bladder irritants, therefore they should be avoided to decrease the risk of cystitis. It is recommended to drink six to eight 8-oz glasses of water daily. Fruit juices are acceptable.

Question 22

A 52-year-old male patient presents to the office following a brief hospitalization for pyelonephritis. He is currently on the second day of a 7-day course of antibiotic. Patient education includes which of the following?

1. If you develop dysuria, increase PO fluids for two days.
2. Continue your antibiotic until you are asymptomatic.
3. Return to the office in 7–10 days for a repeat urinalysis, as well as a urine culture and sensitivity.
4. If you develop urinary frequency, decrease PO fluid intake.

Answer 22

3. Return to the office in 7–10 days for a repeat urinalysis, as well as a urine culture and sensitivity.

The patient should complete the entire course of the prescribed antibiotic. If symptoms of cystitis develop, he should contact his health care provider immediately. The patient should return to the office for a repeat urinalysis and urine culture once the antibiotic treatment is completed. Increasing PO fluid intake is also encouraged.

Question 23

Acute renal failure is diagnosed when the estimated glomerular filtration rate is below which of the following?

1. 5 mL/min
2. 10 mL/min
3. 15 mL/min
4. 25 mL/min

Answer 23

3. 15 mL/min

Acute renal failure, also known as end-stage renal disease, occurs when the eGFR < 15 mL/min.

Question 24

What is the leading cause of acute renal failure?

1. Hypotension
2. Anemia
3. Prostate cancer
4. Diabetes mellitus

Answer 24

4. Diabetes mellitus

Uncontrolled diabetes mellitus and hypertension are the most common causes of kidney disease.

Question 25

Kidney disease is associated with which of the most dangerous electrolyte imbalances?

1. Hypermagnesemia
2. Hyponatremia
3. Hyperkalemia
4. Hypercalcemia

Answer 25

3. Hyperkalemia

Kidney disease often causes hyperkalemia, which can lead to dangerous cardiac arrhythmias.

Question 26

A 66-year-old man with a past medical history that includes chronic kidney disease comes to the clinic. When discussing nutrition, he needs to know he should eat which of the following diets?

1. High carbohydrate, high protein diet
2. High calcium, high potassium, low protein diet
3. Low protein, low sodium, low potassium diet
4. Low protein, high potassium

Answer 26

3. Low protein, low sodium, low potassium diet

Patients with chronic kidney disease need to consume a low-protein, low-sodium, and low-potassium diet. The sub-functioning kidney cannot adequately excrete the by-products of protein metabolism. A low-sodium diet will help control hypertension.

Question 27

The FNP is seeing a 32-year-old male who states: “I think I’m having kidney stones again.” The FNP expects the patient to describe his pain as:

1. Dull and aching pain in the costovertebral area.
2. Diffused abdominal aching and cramp-like pain.
3. Sharp pain radiating to the spine.
4. Excruciating pain that comes and goes and radiates to the groin.

Answer 27

4. Excruciating pain that comes and goes and radiates to the groin.

Renal colic pain is often described as excruciating pain that waxes and wanes.

Question 28

A 44-year-old male with a history of kidney stones is being seen in the primary care clinic. In reviewing his chart, it is noted that the patient’s kidney stones are made up of uric acid crystals. He should be told to avoid which of the following?

1. Milk
2. Liver
3. Apples
4. Carrots

Answer 28

2. Liver

Uric acid can be decreased by consuming a low purine diet. Cheese, red meats, and wine should be avoided.

Question 29

A 59-year-old man comes to the office for follow-up of his hypertension. His blood pressure today is 128/82. While reviewing his recent laboratory value, it is noted that his creatinine is 1.9 mg/dL. Which of his following medications should be discontinued at this time?

1. Beta-blockers
2. Calcium-channel blockers
3. Direct-acting vasodilators
4. Angiotensin-converting enzyme inhibitors

Answer 29

4. Angiotensin-converting enzyme inhibitors

Angiotensin-converting enzyme inhibitors are contraindicated in kidney disease.

Question 30

Which of the following is NOT a normal kidney change resulting from aging?

1. Decreased bladder capacity
2. Nocturnal polyuria
3. Kidney enlargement
4. Decreased glomerular filtration rate

Answer 30

3. Kidney enlargement

Aging causes the kidneys to shrink resulting in loss of cortical kidney tissue. This is a result of decreased renal blood flow.