Exam 5 Iggy 9th Ed Questions

Question 1

Chapter 61: Assessment of the Endocrine System

Answer 1

Ain’t much to this…

Question 2

5. A nurse prepares to palpate a clients thyroid gland. Which action should the nurse take when performing this assessment?
   a. Stand in front of the client instead of behind the client.
   b. Ask the client to swallow after palpating the thyroid.
   c. Palpate the right lobe with the nurses left hand.
   d. Place the client in a sitting position with the chin tucked down.

Answer 2

d. Place the client in a sitting position with the chin tucked down.

The client should be in a sitting position with the chin tucked down as the examiner stands behind the client. The nurse feels for the thyroid isthmus while the client swallows and turns the head to the right, and the nurse palpates the right lobe with the right hand. The technique is repeated in the opposite fashion for the left lobe.

Question 3

6. A nurse collaborates with an unlicensed assistive personnel (UAP) to provide care for a client who is prescribed a 24-hour urine specimen collection. Which statement should the nurse include when delegating this activity to the UAP?
   a. Note the time of the client’s first void and collect urine for 24 hours.
   b. Add the preservative to the container at the end of the test.
   c. Start the collection by saving the first urine of the morning.
   d. It is okay if one urine sample during the 24 hours is not collected.

Answer 3

a. Note the time of the clients first void and collect urine for 24 hours.

The collection of a 24-hour urine specimen is often delegated to a UAP. The nurse must ensure that the UAP understands the proper process for collecting the urine. The 24-hour urine collection specimen is started after the clients first urination. The first urine specimen is discarded because there is no way to know how long it has been in the bladder, but the time of the clients first void is noted. The client adds all urine voided after that first discarded specimen during the next 24 hours. When the 24-hour mark is reached, the client voids one last time and adds this specimen to the collection. The preservative, if used, must be added to the container at the beginning of the collection. All urine samples need to be collected for the test results to be accurate.

Question 4

Chapter 63: Care of Patients with Problems of the Thyroid and Parathyroid Glands

Answer 4

Goiters Goiters Goiters

Question 5

2. A nurse assesses a client who is recovering from a total thyroidectomy and notes the development of stridor. Which action should the nurse take first?
   a. Reassure the client that the voice change is temporary.
   b. Document the finding and assess the client hourly.
   c. Place the client in high-Fowlers position and apply oxygen.
   d. Contact the provider and prepare for intubation.

Answer 5

d. Contact the provider and prepare for intubation.

Stridor on exhalation is a hallmark of respiratory distress, usually caused by obstruction resulting from edema. One emergency measure is to remove the surgical clips to relieve the pressure. This might be a physician function. The nurse should prepare to assist with emergency intubation or tracheostomy while notifying the provider or the Rapid Response Team. Stridor is an emergency situation; therefore, reassuring the client, documenting, and reassessing in an hour do not address the urgency of the situation. Oxygen should be applied, but this action will not keep the airway open.

Question 6

3. A nurse assesses a client who is recovering from a subtotal thyroidectomy. On the second postoperative day the client states, I feel numbness and tingling around my mouth. What action should the nurse take?
   a. Offer mouth care.
   b. Loosen the dressing.
   c. Assess for Chvosteks sign.
   d. Ask the client orientation questions.

Answer 6

c. Assess for Chvosteks sign.

Numbness and tingling around the mouth or in the fingers and toes are manifestations of hypocalcemia, which could progress to cause tetany and seizure activity. The nurse should assess the client further by testing for Chvosteks sign and Trousseaus sign. Then the nurse should notify the provider. Mouth care, loosening the dressing, and orientation questions do not provide important information to prevent complications of low calcium levels.

Question 7

4. A nurse assesses a client on the medical-surgical unit. Which statement made by the client should alert the nurse to the possibility of hypothyroidism?
   a. My sister has thyroid problems.
   b. I seem to feel the heat more than other people.
   c. Food just doesnt taste good without a lot of salt.
   d. I am always tired, even with 12 hours of sleep.

Answer 7

d. I am always tired, even with 12 hours of sleep.

Clients with hypothyroidism usually feel tired or weak despite getting many hours of sleep. Thyroid problems are not inherited. Heat intolerance is indicative of hyperthyroidism. Loss of taste is not a manifestation of hypothyroidism.

Question 8

5. A nurse cares for a client who presents with bradycardia secondary to hypothyroidism. Which medication should the nurse anticipate being prescribed to the client?
   a. Atropine sulfate
   b. Levothyroxine sodium (Synthroid)
   c. Propranolol (Inderal)
   d. Epinephrine (Adrenalin)

Answer 8

b. Levothyroxine sodium (Synthroid)

The treatment for bradycardia from hypothyroidism is to treat the hypothyroidism using levothyroxine sodium. If the heart rate were so slow that it became an emergency, then atropine or epinephrine might be an option for short-term management. Propranolol is a beta blocker and would be contraindicated for a client with bradycardia.

Question 9

6. A nurse plans care for a client with hypothyroidism. Which priority problem should the nurse plan to address first for this client?
   a. Heat intolerance
   b. Body image problems
   c. Depression and withdrawal
   d. Obesity and water retention

Answer 9

c. Depression and withdrawal

Hypothyroidism causes many problems in psychosocial functioning. Depression is the most common reason for seeking medical attention. Memory and attention span may be impaired. The clients family may have great difficulty accepting and dealing with these changes. The client is often unmotivated to participate in self-care. Lapses in memory and attention require the nurse to ensure that the clients environment is safe. Heat intolerance is seen in hyperthyroidism. Body image problems and weight issues do not take priority over mental status and safety.

Question 10

7. A nurse assesses a client who is prescribed levothyroxine (Synthroid) for hypothyroidism. Which assessment finding should alert the nurse that the medication therapy is effective?
   a. Thirst is recognized and fluid intake is appropriate.
   b. Weight has been the same for 3 weeks.
   c. Total white blood cell count is 6000 cells/mm3.
   d. Heart rate is 70 beats/min and regular.

Answer 10

d. Heart rate is 70 beats/min and regular.

Hypothyroidism decreases body functioning and can result in effects such as bradycardia, confusion, and constipation. If a clients heart rate is bradycardic while on thyroid hormone replacement, this is an indicator that the replacement may not be adequate. Conversely, a heart rate above 100 beats/min may indicate that the client is receiving too much of the thyroid hormone. Thirst, fluid intake, weight, and white blood cell count do not represent a therapeutic response to this medication.

Question 11

8. A nurse cares for a client who has hypothyroidism as a result of Hashimoto’s thyroiditis. The client asks, “How long will I need to take this thyroid medication?”
   How should the nurse respond?

a. You will need to take the thyroid medication until the goiter is completely gone.
b. Thyroiditis is cured with antibiotics. Then you won’t need thyroid medication.
c. You’ll need thyroid pills for life because your thyroid won’t start working again.
d. When blood tests indicate normal thyroid function, you can stop the medication.

Answer 11

c. You’ll need thyroid pills for life because your thyroid won’t start working again.

Hashimoto’s thyroiditis results in a permanent loss of thyroid function. The client will need lifelong thyroid replacement therapy. The client will not be able to stop taking the medication.

Question 12

9. A nurse assesses clients for potential endocrine disorders. Which client is at the greatest risk for hyperparathyroidism?
   a. A 29-year-old female with pregnancy-induced hypertension
   b. A 41-year-old male receiving dialysis for end-stage kidney disease
   c. A 66-year-old female with moderate heart failure
   d. A 72-year-old male who is prescribed home oxygen therapy

Answer 12

b. A 41-year-old male receiving dialysis for end-stage kidney disease.

Clients who have chronic kidney disease do not completely activate vitamin D and poorly absorb calcium from the GI tract. They are chronically hypocalcemic, and this triggers overstimulation of the parathyroid glands. Pregnancy-induced hypertension, moderate heart failure, and home oxygen therapy do not place a client at higher risk for hyperparathyroidism.

Question 13

10. A nurse plans care for a client with hyperparathyroidism. Which intervention should the nurse include in this client’s plan of care?
    a. Ask the client to ambulate in the hallway twice a day.
    b. Use a lift sheet to assist the client with position changes.
    c. Provide the client with a soft-bristled toothbrush for oral care.
    d. Instruct the unlicensed assistive personnel to strain the client’s urine for stones.

Answer 13

b. Use a lift sheet to assist the client with position changes.

Hyperparathyroidism causes increased resorption of calcium from the bones, increasing the risk for pathologic fractures. Using a lift sheet when moving or positioning the client, instead of pulling on the client, reduces the risk of bone injury.
Hyperparathyroidism can cause kidney stones, but not every client will need to have urine strained. The priority is preventing injury. Ambulating in the hall and using a soft toothbrush are not specific interventions for this client.

Question 14

11. A nurse cares for a client who is recovering from a parathyroidectomy. When taking the client’s blood pressure, the nurse notes that the client’s hand has gone into flexion contractions. Which laboratory result does the nurse correlate with this condition?
    a. Serum potassium: 2.9 mEq/L
    b. Serum magnesium: 1.7 mEq/L
    c. Serum sodium: 122 mEq/L
    d. Serum calcium: 6.9 mg/dL

Answer 14

d. Serum calcium: 6.9 mg/dL

Hypocalcemia destabilizes excitable membranes and can lead to muscle twitches, spasms, and tetany. This effect of hypocalcemia is enhanced in the presence of tissue hypoxia. The flexion contractions (Trousseau’s sign) that occur during blood pressure measurement are indicative of hypocalcemia, not the other electrolyte imbalances, which include hypokalemia, hyponatremia, and hypomagnesemia.

Question 15

12. A nurse cares for a client newly diagnosed with Graves disease. The client’s mother asks, “I have diabetes mellitus. Am I responsible for my daughter’s disease?” How should the nurse respond?

a. The fact that you have diabetes did not cause your daughter to have Graves disease. No connection is known between Graves disease and diabetes.
b. An association has been noted between Graves disease and diabetes, but the fact that you have diabetes did not cause your daughter to have Graves disease.
c. Graves disease is associated with autoimmune diseases such as rheumatoid arthritis, but not with a disease such as diabetes mellitus.
d. Unfortunately, Graves disease is associated with diabetes, and your diabetes could have led to your daughter having Graves disease.

Answer 15

b. An association has been noted between Graves disease and diabetes, but the fact that you have diabetes did not cause your daughter to have Graves disease.

An association between autoimmune diseases such as rheumatoid arthritis and diabetes mellitus has been noted. The predisposition is probably polygenic, and the mothers diabetes did not cause her daughters Graves disease. The other statements are inaccurate.

Question 16

13. While assessing a client with Graves disease, the nurse notes that the client’s temperature has risen 1 F. Which action should the nurse take first?
    a. Turn the lights down and shut the client’s door.
    b. Call for an immediate electrocardiogram (ECG).
    c. Calculate the client’s apical-radial pulse deficit.
    d. Administer a dose of acetaminophen (Tylenol).

Answer 16

a. Turn the lights down and shut the clients door.

A temperature increase of 1 F may indicate the development of thyroid storm, and the provider needs to be notified. But before notifying the provider, the nurse should take measures to reduce environmental stimuli that increase the risk of cardiac complications. The nurse can then call for an ECG. The apical-radial pulse deficit would not be necessary, and Tylenol is not needed because the temperature increase is due to thyroid activity.

Question 17

14. After teaching a client who is recovering from a complete thyroidectomy, the nurse assesses the client’s understanding. Which statement made by the client indicates a need for additional instruction?
    a. I may need calcium replacement after surgery.
    b. After surgery, I won’t need to take thyroid medication.
    c. Ill need to take thyroid hormones for the rest of my life.
    d. I can receive pain medication if I feel that I need it.

Answer 17

b. After surgery, I won’t need to take thyroid medication.

After the client undergoes a thyroidectomy, the client must be given thyroid replacement medication for life. He or she may also need calcium if the parathyroid is damaged during surgery, and can receive pain medication postoperatively.

Question 18

15. A nurse plans care for a client who has hypothyroidism and is admitted for pneumonia. Which priority intervention should the nurse include in this client’s plan of care?
    a. Monitor the client’s intravenous site every shift.
    b. Administer acetaminophen (Tylenol) for fever.
    c. Ensure that working suction equipment is in the room.
    d. Assess the client’s vital signs every 4 hours.

Answer 18

c. Ensure that working suction equipment is in the room.

A client with hypothyroidism who develops another illness is at risk for myxedema coma. In this emergency situation, maintaining an airway is a priority. The nurse should ensure that suction equipment is available in the clients room because it may be needed if myxedema coma develops. The other interventions are necessary for any client with pneumonia, but having suction available is a safety feature for this client.

Question 19

1. A nurse evaluates the following laboratory results for a client who has hypoparathyroidism: 
Calcium 7.2 mg/dL
Sodium 144 mEq/L
Magnesium 1.2 mEq/L
Potassium 5.7 mEq/L

Based on these results, which medications should the nurse anticipate administering? 
(Select all that apply.) 
a. Oral potassium chloride
b. Intravenous calcium chloride
c. 3% normal saline IV solution
d. 50% magnesium sulfate
e. Oral calcitriol (Rocaltrol)

Answer 19

b. Intravenous calcium chloride.
d. 50% magnesium sulfate

The client has hypocalcemia (treated with calcium chloride) and hypomagnesemia (treated with magnesium sulfate). The potassium level is high, so replacement is not needed. The clients sodium level is normal, so hypertonic IV solution is not needed. No information about a vitamin D deficiency is evident, so calcitriol is not needed.

Question 20

2. A nurse cares for a client with elevated triiodothyronine (T3) and thyroxine (T4), and normal thyroid-stimulating hormone (TSH) levels. Which actions should the nurse take? (Select all that apply.)

a. Administer levothyroxine (Synthroid).
b. Administer propranolol (Inderal).
c. Monitor the apical pulse.
d. Assess for Trousseaus sign.
e. Initiate telemetry monitoring.

Answer 20

c. Monitor the apical pulse.
e. Initiate telemetry monitoring.

The client’s laboratory findings suggest that the client is experiencing hyperthyroidism. The increased metabolic rate can cause an increase in the client’s heart rate, and the client should be monitored for the development of dysrhythmias. Placing the client on a telemetry monitor might also be a precaution. Levothyroxine is given for hypothyroidism. Propranolol is a beta-blocker often used to lower sympathetic nervous system activity in hyperthyroidism. Trousseau’s sign is a test for hypocalcemia.

Question 21

3. A nurse teaches a client with hyperthyroidism. Which dietary modifications should the nurse include in this client’s teaching? (Select all that apply.)
   a. Increased carbohydrates
   b. Decreased fats
   c. Increased calorie intake
   d. Supplemental vitamins
   e. Increased proteins

Answer 21

a. Increased carbohydrates
c. Increased calorie intake
e. Increased proteins

The client is hypermetabolic and has an increased need for carbohydrates, calories, and proteins. Proteins are especially important because the client is at risk for a negative nitrogen balance. There is no need to decrease fat intake or take supplemental vitamins.

Question 22

4. A nurse assesses a client with hypothyroidism who is admitted with acute appendicitis. The nurse notes that the client’s level of consciousness has decreased. Which actions should the nurse take? (Select all that apply.)
   a. Infuse intravenous fluids.
   b. Cover the client with warm blankets.
   c. Monitor blood pressure every 4 hours.
   d. Maintain a patent airway.
   e. Administer oral glucose as prescribed.

Answer 22

a. Infuse intravenous fluids.
b. Cover the client with warm blankets.
d. Maintain a patent airway.

A client with hypothyroidism and an acute illness is at risk for myxedema coma. A decrease in level of consciousness is a symptom of myxedema. The nurse should infuse IV fluids, cover the client with warm blankets, monitor blood pressure every hour, maintain a patent airway, and administer glucose INTRAVENOUSLY as prescribed.

Question 23

5. A nurse teaches a client who is prescribed an unsealed radioactive isotope. Which statements should the nurse include in this client’s education?
   (Select all that apply.)
   a. Do not share utensils, plates, and cups with anyone else.
   b. You can play with your grandchildren for 1 hour each day.
   c. Eat foods high in vitamins such as apples, pears, and oranges.
   d. Wash your clothing separately from others in the household.
   e. Take a laxative 2 days after therapy to excrete the radiation.

Answer 23

a. Do not share utensils, plates, and cups with anyone else.
d. Wash your clothing separate from others in the household.
e. Take a laxative 2 days after therapy to excrete the radiation.

A client who is prescribed an unsealed radioactive isotope should be taught to not share utensils, plates, and cups with anyone else; to avoid contact with pregnant women and children; to avoid eating foods with cores or bones, which will leave contaminated remnants; to wash clothing separate from others in the household and run an empty cycle before washing other people’s clothing; and to take a laxative on days 2 and 3 after receiving treatment to help excrete the contaminated stool faster.

Question 24

Chapter 64: Care of Patients with Diabetes Mellitus

Answer 24

Diiiiiiabetes

Question 25

1. A nurse is teaching a client with diabetes mellitus who asks, Why is it necessary to maintain my blood glucose levels no lower than about 60 mg/dL? How should the nurse respond?
   a. Glucose is the only fuel used by the body to produce the energy that it needs.
   b. Your brain needs a constant supply of glucose because it cannot store it.
   c. Without a minimum level of glucose, your body does not make red blood cells.
   d. Glucose in the blood prevents the formation of lactic acid and prevents acidosis.

Answer 25

b. Your brain needs a constant supply of glucose because it cannot store it.

Because the brain cannot synthesize or store significant amounts of glucose, a continuous supply from the body’s circulation is needed to meet the fuel demands of the central nervous system. The nurse would want to educate the client to prevent hypoglycemia. The body can use other sources of fuel, including fat and protein, and glucose is not involved in the production of red blood cells. Glucose in the blood will encourage glucose metabolism but is not directly responsible for lactic acid formation.

Question 26

2. A nurse reviews laboratory results for a client with diabetes mellitus who presents with polyuria, lethargy, and a blood glucose of 560 mg/dL. Which laboratory result should the nurse correlate with the client’s polyuria?
   a. Serum sodium: 163 mEq/L
   b. Serum creatinine: 1.6 mg/dL
   c. Presence of urine ketone bodies
   d. Serum osmolarity: 375 mOsm/kg

Answer 26

d. Serum osmolarity: 375 mOsm/kg

Hyperglycemia causes hyperosmolarity of extracellular fluid. This leads to polyuria from osmotic diuresis. The client’s serum osmolarity is high. The client’s sodium would be expected to be high owing to dehydration. Serum creatinine and urine ketone bodies are not related to polyuria.

Question 27

3. After teaching a young adult client who is newly diagnosed with type 1 diabetes mellitus, the nurse assesses the client’s understanding. Which statement made by the client indicates a correct understanding of the need for eye examinations?
   a. At my age, I should continue seeing the ophthalmologist as I usually do.
   b. I will see the eye doctor when I have a vision problem and yearly after age 40.
   c. My vision will change quickly. I should see the ophthalmologist twice a year.
   d. Diabetes can cause blindness, so I should see the ophthalmologist yearly.

Answer 27

d. Diabetes can cause blindness, so I should see the ophthalmologist yearly.

Diabetic retinopathy is a leading cause of blindness in North America. All clients with diabetes, regardless of age, should be examined by an ophthalmologist (rather than an optometrist or optician) at diagnosis and at least yearly thereafter.

Question 28

4. A nurse assesses a client who has a 15-year history of diabetes and notes decreased tactile sensation in both feet. Which action should the nurse take first?
   a. Document the finding in the client’s chart.
   b. Assess tactile sensation in the client’s hands.
   c. Examine the client’s feet for signs of injury.
   d. Notify the health care provider.

Answer 28

c. Examine the client’s feet for signs of injury.

Diabetic neuropathy is common when the disease is of long duration. The client is at great risk for injury in any area with decreased sensation because he or she is less able to feel injurious events. Feet are common locations for neuropathy and injury, so the nurse should inspect them for any signs of injury. After assessment, the nurse should document findings in the client’s chart. Testing sensory perception in the hands may or may not be needed. The health care provider can be notified after assessment and documentation have been completed.

Question 29

5. A nurse cares for a client who has a family history of diabetes mellitus. The client states, “My father has type 1 diabetes mellitus. Will I develop this disease as well?” How should the nurse respond?
   a. Your risk of diabetes is higher than the general population, but it may not occur.
   b. No genetic risk is associated with the development of type 1 diabetes mellitus.
   c. The risk for becoming a diabetic is 50% because of how it is inherited.
   d. Female children do not inherit diabetes mellitus, but male children will.

Answer 29

a. Your risk of diabetes is higher than the general population, but it may not occur.

Risk for type 1 diabetes is determined by inheritance of genes coding for HLA-DR and HLA-DQ tissue types. Clients who have one parent with type 1 diabetes are at increased risk for its development. Diabetes (type 1) seems to require interaction between inherited risk and environmental factors, so not everyone with these genes develops diabetes. The other statements are not accurate.

Question 30

6. A nurse teaches a client who is diagnosed with diabetes mellitus. Which statement should the nurse include in this client’s plan of care to delay the onset of microvascular and macrovascular complications?
   a. Maintain tight glycemic control and prevent hyperglycemia.
   b. Restrict your fluid intake to no more than 2 liters a day.
   c. Prevent hypoglycemia by eating a bedtime snack.
   d. Limit your intake of protein to prevent ketoacidosis.

Answer 30

a. Maintain tight glycemic control and prevent hyperglycemia.

Hyperglycemia is a critical factor in the pathogenesis of long-term diabetic complications. Maintaining tight glycemic control will help delay the onset of complications. Restricting fluid intake is not part of the treatment plan for clients with diabetes. Preventing hypoglycemia and ketosis, although important, are not as important as maintaining daily glycemic control.

Question 31

7. A nurse assesses clients who are at risk for diabetes mellitus. Which client is at greatest risk?
   a. A 29-year-old Caucasian
   b. A 32-year-old African-American
   c. A 44-year-old Asian
   d. A 48-year-old American Indian

Answer 31

d. A 48-year-old American Indian

Diabetes is a particular problem among African Americans, Hispanics, and American Indians. The incidence of diabetes increases in all races and ethnic groups with age. Being both an American Indian and middle-aged places this client at the highest risk.

Question 32

8. A nurse teaches a client about self-monitoring of blood glucose levels. Which statement should the nurse include in this client’s teaching to prevent bloodborne infections?
   a. Wash your hands after completing each test.
   b. Do not share your monitoring equipment.
   c. Blot excess blood from the strip with a cotton ball.
   d. Use gloves when monitoring your blood glucose.

Answer 32

b. Do not share your monitoring equipment.

Small particles of blood can adhere to the monitoring device, and infection can be transported from one user to another. Hepatitis B in particular can survive in a dried state for about a week. The client should be taught to avoid sharing any equipment, including the lancet holder. The client should be taught to wash his or her hands before testing. The client would not need to blot excess blood away from the strip or wear gloves.

Question 33

12. A nurse cares for a client with diabetes mellitus who asks, Why do I need to administer more than one injection of insulin each day? How should the nurse respond?
    a. You need to start with multiple injections until you become more proficient at self-injection.
    b. A single dose of insulin each day would not match your blood insulin levels and your food intake patterns.
    c. A regimen of a single dose of insulin injected each day would require that you eat fewer carbohydrates.
    d. A single dose of insulin would be too large to be absorbed, predictably putting you at risk for insulin shock.

Answer 33

b. A single dose of insulin each day would not match your blood insulin levels and your food intake patterns.

Even when a single injection of insulin contains a combined dose of different-acting insulin types, the timing of the actions and the timing of food intake may not match well enough to prevent wide variations in blood glucose levels. One dose of insulin would not be appropriate even if the client decreased carbohydrate intake. Additional injections are not required to allow the client to practice with injections, nor will one dose increase the client’s risk of insulin shock.

Question 34

13. After teaching a client with diabetes mellitus to inject insulin, the nurse assesses the client’s understanding. Which statement made by the client indicates a need for additional teaching?
    a. The lower abdomen is the best location because it is closest to the pancreas.
    b. I can reach my thigh the best, so I will use the different areas of my thighs.
    c. By rotating the sites in one area, my chance of having a reaction is decreased.
    d. Changing injection sites from the thigh to the arm will change absorption rates.

Answer 34

a. The lower abdomen is the best location because it is closest to the pancreas.

The abdominal site has the fastest rate of absorption because of blood vessels in the area, not because of its proximity to the pancreas. The other statements are accurate assessments of insulin administration.

Question 35

14. A nurse assesses a client with diabetes mellitus and notes the client only responds to a sternal rub by moaning, has a capillary blood glucose of 33 g/dL, and has an intravenous line that is infiltrated with 0.45% normal saline. Which action should the nurse take first?
    a. Administer 1 mg of intramuscular glucagon.
    b. Encourage the client to drink orange juice.
    c. Insert a new intravenous access line.
    d. Administer 25 mL dextrose 50% (D50) IV push.

Answer 35

a. Administer 1 mg of intramuscular glucagon.

The client’s blood glucose level is dangerously low. The nurse needs to administer glucagon IM immediately to increase the client’s blood glucose level. The nurse should insert a new IV after administering the glucagon and can use the new IV site for future doses of D50 if the client’s blood glucose level does not rise. Once the client is awake, orange juice may be administered orally along with a form of protein such as a peanut butter.

Question 36

15. A nurse cares for a client with diabetes mellitus who is visually impaired. The client asks, Can I ask my niece to prefill my syringes and then store them for later use when I need them? How should the nurse respond?
    a. Yes. Prefilled syringes can be stored for 3 weeks in the refrigerator in a vertical position with the needle pointing up.
    b. Yes. Syringes can be filled with insulin and stored for a month in a location that is protected from light.
    c. Insulin reacts with plastic, so prefilled syringes are okay, but you will need to use glass syringes.
    d. No. Insulin syringes cannot be prefilled and stored for any length of time outside of the container.

Answer 36

a. Yes. Prefilled syringes can be stored for 3 weeks in the refrigerator in a vertical position with the needle pointing up.

Insulin is relatively stable when stored in a cool, dry place away from light. When refrigerated, prefilled plastic syringes are stable for up to 3 weeks. They should be stored in the refrigerator in the vertical position with the needle pointing up to prevent suspended insulin particles from clogging the needle.

Question 37

16. A nurse teaches a client who is prescribed an insulin pump. Which statement should the nurse include in this client’s discharge education?
    a. Test your urine daily for ketones.
    b. Use only buffered insulin in your pump.
    c. Store the insulin in the freezer until you need it.
    d. Change the needle every 3 days.

Answer 37

d. Change the needle every 3 days.

Having the same needle remain in place through the skin for longer than 3 days drastically increases the risk for infection in or through the delivery system. Having an insulin pump does not require the client to test for ketones in the urine. Insulin should not be frozen. Insulin is not buffered.

Question 38

17. After teaching a client who has diabetes mellitus and proliferative retinopathy, nephropathy, and peripheral neuropathy, the nurse assesses the client’s understanding. Which statement made by the client indicates a correct understanding of the teaching?
    a. I have so many complications; exercising is not recommended.
    b. I will exercise more frequently because I have so many complications.
    c. I used to run for exercise; I will start training for a marathon.
    d. I should look into swimming or water aerobics to get my exercise.

Answer 38

d. I should look into swimming or water aerobics to get my exercise.

Exercise is not contraindicated for this client, although modifications based on existing pathology are necessary to prevent further injury. Swimming or water aerobics will give the client exercise without the worry of having the correct shoes or developing a foot injury. The client should not exercise too vigorously.

Question 39

18. An emergency department nurse assesses a client with ketoacidosis. Which clinical manifestation should
    the nurse correlate with this condition?
    a. Increased rate and depth of respiration
    b. Extremity tremors followed by seizure
    activity
    c. Oral temperature of 102 F (38.9 C)
    d. Severe orthostatic hypotension

Answer 39

a. Increased rate and depth of respiration

Ketoacidosis decreases the pH of the blood, stimulating the respiratory control areas of the brain to buffer the
effects of increasing acidosis. The rate and depth of respiration are increased (Kussmaul respirations) in an
attempt to excrete more acids by exhalation. Tremors, elevated temperature, and orthostatic hypotension are
not associated with ketoacidosis.

Question 40

19. A nurse assesses a client who has diabetes mellitus. Which arterial blood gas values should the nurse identify as potential ketoacidosis in this client?
    a. pH 7.38, HCO3 22 mEq/L, PCO2 38 mm Hg, PO2 98 mm Hg
    b. pH 7.28, HCO3 18 mEq/L, PCO2 28 mm Hg, PO2 98 mm Hg
    c. pH 7.48, HCO3 28 mEq/L, PCO2 38 mm Hg, PO2 98 mm Hg
    d. pH 7.32, HCO3 22 mEq/L, PCO2 58 mm Hg, PO2 88 mm Hg

Answer 40

b. pH 7.28,
HCO3 18 mEq/L,
PCO2 28 mm Hg,
PO2 98 mm Hg

When the lungs can no longer offset acidosis, the pH decreases to below normal. A client who has diabetic
ketoacidosis would present with arterial blood gas values that show primary metabolic acidosis with decreased
bicarbonate levels and a compensatory respiratory alkalosis with decreased carbon dioxide levels.

Question 41

20. A nurse cares for a client experiencing diabetic ketoacidosis who presents with Kussmaul respirations. Which action should the nurse take?
    a. Administration of oxygen via face mask
    b. Intravenous administration of 10% glucose
    c. Implementation of seizure precautions
    d. Administration of intravenous insulin

Answer 41

d. Administration of intravenous insulin

The rapid, deep respiratory efforts of Kussmaul respirations are the body’s attempt to reduce the acids produced by using fat rather than glucose for fuel. Only the administration of insulin will reduce this type of respiration by assisting glucose to move into cells and to be used for fuel instead of fat. The client who is in ketoacidosis may not experience any respiratory impairment and therefore does not need additional oxygen. Giving the client glucose would be contraindicated. The client does not require seizure precautions.

Question 42

21. A nurse cares for a client who has type 1 diabetes mellitus. The client asks, “Is it okay for me to have an occasional glass of wine?” How should the nurse respond?
    a. Drinking any wine or alcohol will increase your insulin requirements.
    b. Because of poor kidney function, people with diabetes should avoid
    alcohol.
    c. You should not drink alcohol because it will make you hungry and overeat.
    d. One glass of wine is okay with a meal and is counted as two fat exchanges

Answer 42

d. One glass of wine is okay with a meal and is counted as two fat exchanges

Under normal circumstances, blood glucose levels will not be affected by moderate use of alcohol when diabetes is well controlled. Because alcohol can induce hypoglycemia, it should be ingested with or shortly
after a meal. One alcoholic beverage is substituted for two fat exchanges when caloric intake is calculated. Kidney function is not impacted by alcohol intake. Alcohol is not associated with increased hunger or
overeating.

Question 43

22. A nurse teaches a client with type 1 diabetes mellitus. Which statement should the nurse include in this client’s teaching to decrease the client’s insulin needs?

a. Limit your fluid intake to 2 liters a day.
b. Animal organ meat is high in insulin.
c. Limit your carbohydrate intake to 80 grams/day.
d. Walk at a moderate pace for 1 mile daily

Answer 43

d. Walk at a moderate pace for 1 mile daily

Moderate exercise such as walking helps regulate blood glucose levels on a daily basis and results in lowered insulin requirements for clients with type 1 diabetes mellitus. Restricting fluids and eating organ meats will not reduce insulin needs. People with diabetes need at least 130 grams of carbohydrates each day.

Question 44

23. A nurse cares for a client who is diagnosed with acute rejection 2 months after receiving a simultaneous
    pancreas-kidney transplant. The client states, “I was doing so well with my new organs, and the thought of having to go back to living on hemodialysis and taking insulin is so depressing.” How should the nurse respond?
    a. Following the drug regimen more closely would have prevented this.
    b. One acute rejection episode does not mean that you will lose the new organs.
    c. Dialysis is a viable treatment option for you and may save your life.
    d. Since you are on the national registry, you can receive a second
    transplantation.

Answer 44

b. One acute rejection episode does not mean that you will lose the new organs.

An episode of acute rejection does not automatically mean that the client will lose the transplant. Pharmacologic manipulation of host immune responses at this time can limit damage to the organ and allow the graft to be maintained. The other statements either belittle the client or downplay his or her concerns. The client may not be a candidate for additional organ transplantation.

Question 45

24. After teaching a client who is recovering from pancreas transplantation, the nurse assesses the client’s understanding. Which statement made by the client indicates a need for additional education?
    a. If I develop an infection, I should stop taking my corticosteroid.
    b. If I have pain over the transplant site, I will call the surgeon immediately.
    c. I should avoid people who are ill or who have an infection.
    d. I should take my cyclosporine exactly the way I was taught.

Answer 45

a. If I develop an infection, I should stop taking my corticosteroid.

Immunosuppressive agents should not be stopped without the consultation of the transplantation physician, even if an infection is present. Stopping immunosuppressive therapy endangers the transplanted organ. The
other statements are correct. Pain over the graft site may indicate rejection. Anti-rejection drugs cause
immunosuppression, and the client should avoid crowds and people who are ill. Changing the routine of anti-rejection medications may cause them to not work optimally.

Question 46

25. A nurse assesses a client with diabetes mellitus 3 hours after a surgical procedure and notes the client’s breath has a fruity odor. Which action should the nurse take?
    a. Encourage the client to use an incentive spirometer.
    b. Increase the client’s intravenous fluid flow rate.
    c. Consult the provider to test for ketoacidosis.
    d. Perform meticulous pulmonary hygiene care.

Answer 46

c. Consult the provider to test for ketoacidosis.

The stress of surgery increases the action of counterregulatory hormones and suppresses the action of insulin, predisposing the client to ketoacidosis and metabolic acidosis. One manifestation of ketoacidosis is a fruity odor to the breath. Documentation should occur after all assessments have been completed. Using an incentive spirometer, increasing IV fluids, and performing pulmonary hygiene will not address this clients problem.

Question 47

26. A preoperative nurse assesses a client who has type 1 diabetes mellitus prior to a surgical procedure. The
    client’s blood glucose level is 160 mg/dL. Which action should the nurse take?
    a. Document the finding in the client’s chart.
    b. Administer a bolus of regular insulin IV.
    c. Call the surgeon to cancel the procedure.
    d. Draw blood gases to assess the metabolic
    state.

Answer 47

a. Document the finding in the client’s chart.

Clients who have type 1 diabetes and are having surgery have been found to have fewer complications, lower rates of infection, and better wound healing if blood glucose levels are maintained at between 140 and 180 mg/dL throughout the perioperative period. The nurse should document the finding and proceed with other
operative care. The need for a bolus of insulin, canceling the procedure, or drawing arterial blood gases is not
required.

Question 48

27. A nurse teaches a client with diabetes mellitus who is experiencing numbness and reduced sensation. Which statement should the nurse include in this client’s teaching to prevent injury?
    a. Examine your feet using a mirror every day.
    b. Rotate your insulin injection sites every week.
    c. Check your blood glucose level before each meal.
    d. Use a bath thermometer to test the water temperature.

Answer 48

d. Use a bath thermometer to test the water temperature.

Clients with diminished sensory perception can easily experience a burn injury when bathwater is too hot. Instead of checking the temperature of the water by feeling it, they should use a thermometer. Examining the feet daily does not prevent injury, although daily foot examinations are important to find problems so they can be addressed. Rotating insulin and checking blood glucose levels will not prevent injury.

Question 49

28. A nurse reviews the medication list of a client with a 20-year history of diabetes mellitus. The client holds
    up the bottle of prescribed duloxetine (Cymbalta) and states, “My cousin has depression and is taking this drug. Do you think I’m depressed?” How should the nurse respond?
    a. Many people with long-term diabetes become depressed after a while.
    b. It’s for peripheral neuropathy. Do you have burning pain in your feet or hands?
    c. This antidepressant also has anti-inflammatory properties for diabetic pain.
    d. No. Many medications can be used for several different disorders.

Answer 49

b. It’s for peripheral neuropathy. Do you have burning pain in your feet or hands?

Damage along nerves causes peripheral neuropathy and leads to burning pain along the nerves. Many drugs,
including duloxetine (Cymbalta), can be used to treat peripheral neuropathy. The nurse should assess the client for this condition and then should provide an explanation of why this drug is being used. This medication, although it is used for depression, is not being used for that reason in this case. Duloxetine does not have antiinflammatory properties. Telling the client that many medications are used for different disorders does not provide the client with enough information to be useful.

Question 50

29.A nurse assesses a client with diabetes mellitus. Which clinical manifestation should alert the nurse to decreased kidney function in this client?
a. Urine specific gravity of 1.033
b. Presence of protein in the urine
c. Elevated capillary blood glucose
level
d. Presence of ketone bodies in the urine

Answer 50

b. Presence of protein in the urine

Renal dysfunction often occurs in the client with diabetes. Proteinuria is a result of renal dysfunction. Specific gravity is elevated with dehydration. Elevated capillary blood glucose levels and ketones in the urine are
consistent with diabetes mellitus but are not specific to renal function.

Question 51

30. A nurse develops a dietary plan for a client with diabetes mellitus and new-onset microalbuminuria. Which component of the client’s diet should the nurse decrease?
    a. Carbohydrates
    b. Proteins
    c. Fats
    d. Total calories

Answer 51

b. Proteins

Restriction of dietary protein to 0.8 g/kg of body weight per day is recommended for clients with microalbuminuria to delay progression to renal failure. The client’s diet does not need to be decreased in carbohydrates, fats, or total calories.

Question 52

31. A nurse assesses a client who has diabetes mellitus and notes the client is awake and alert, but shaky, diaphoretic, and weak. Five minutes after administering a half-cup of orange juice, the client’s clinical manifestations have not changed. Which action should the nurse take next?

a. Administer another half-cup of orange juice.
b. Administer a half-ampule of dextrose 50%
intravenously.
c. Administer 10 units of regular insulin subcutaneously.
d. Administer 1 mg of glucagon intramuscularly.

Answer 52

a. Administer another half-cup of orange juice.

This client is experiencing mild hypoglycemia. For mild hypoglycemic manifestations, the nurse should administer oral glucose in the form of orange juice. If the symptoms do not resolve immediately, the treatment should be repeated. The client does not need intravenous dextrose, insulin, or glucagon.

Question 53

32. A nurse reviews the laboratory results of a client who is receiving intravenous insulin. Which should alert the nurse to intervene immediately?
    a. Serum chloride level of 98 mmol/L
    b. Serum calcium level of 8.8 mg/dL
    c. Serum sodium level of 132 mmol/L
    d. Serum potassium level of 2.5 mmol/L

Answer 53

d. Serum potassium level of 2.5 mmol/L

Insulin activates the sodium-potassium ATPase pump, increasing the movement of potassium from the extracellular fluid into the intracellular fluid, resulting in hypokalemia. In hyperglycemia, hypokalemia can also result from excessive urine loss of potassium. The chloride level is normal. The calcium and sodium levels
are slightly low, but this would not be related to hyperglycemia and insulin administration.

Question 54

33. A nurse teaches a client with diabetes mellitus about sick day management. Which statement should the nurse include in this client’s teaching?
    a. When ill, avoid eating or drinking to reduce vomiting and diarrhea.
    b. Monitor your blood glucose levels at least every 4 hours while sick.
    c. If vomiting, do not use insulin or take your oral antidiabetic agent.
    d. Try to continue your prescribed exercise regimen even if you are
    sick.

Answer 54

b. Monitor your blood glucose levels at least every 4 hours while sick.

When ill, the client should monitor his or her blood glucose at least every 4 hours. The client should continue taking the medication regimen while ill. The client should continue to eat and drink as tolerated but should not exercise while sick.

Question 55

34. A nurse assesses a client who is being treated for a hyperglycemic-hyperosmolar state (HHS). Which clinical
    manifestation indicates to the nurse that the therapy needs to be adjusted?
    a. Serum potassium level has increased.
    b. Blood osmolarity has decreased.
    c. Glasgow Coma Scale score is unchanged.
    d. Urine remains negative for ketone bodies.

Answer 55

c. Glasgow Coma Scale score is unchanged.

A slow but steady improvement in central nervous system functioning is the best indicator of therapy
effectiveness for HHS. Lack of improvement in the level of consciousness may indicate inadequate rates of
fluid replacement. The Glasgow Coma Scale assesses the client’s state of consciousness against criteria of a scale including best eye, verbal, and motor responses. An increase in serum potassium, decreased blood
osmolality, and urine negative for ketone bodies do not indicate adequacy of treatment.

Question 56

35. A nurse cares for a client who has diabetes mellitus. The nurse administers 6 units of regular insulin and 10 units of NPH insulin at 0700. At which time should the nurse assess the client for potential problems related to the NPH insulin?
    a. 0800
    b. 1600
    c. 2000
    d. 2300

Answer 56

b. 1600

Neutral protamine Hagedorn (NPH) is an intermediate-acting insulin with an onset of 1.5 hours, a peak of 4 to 12 hours, and a duration of action of 22 hours.
Checking the client at 0800 would be too soon. Checking the client at 2000 and 2300 would be too late.
The nurse should check the client at 1600.

Question 57

36. After teaching a client with type 2 diabetes mellitus, the nurse assesses the client’s understanding. Which statement made by the client indicates a need for additional teaching?
    a. I need to have an annual appointment even if my glucose levels are in good control.
    b. Since my diabetes is controlled with diet and exercise, I must be seen only if I am sick.
    c. I can still develop complications even though I do not have to take insulin at this time.
    d. If I have surgery or get very ill, I may have to receive insulin injections for a short time.

Answer 57

b. Since my diabetes is controlled with diet and exercise, I must be seen only if I am sick.

Clients with diabetes need to be seen at least annually to monitor for long-term complications, including visual
changes, microalbuminuria, and lipid analysis. The client may develop complications and may need insulin in
the future.

Question 58

37. When teaching a client recently diagnosed with type 1 diabetes mellitus, the client states, “I will never be able to stick myself with a needle.” How should the nurse respond?
    a. I can give your injections to you while you are here in the hospital.
    b. Everyone gets used to giving themselves injections. It really does not hurt.
    c. Your disease will not be managed properly if you refuse to administer the
    shots.
    d. Tell me what it is about the injections that are concerning you.

Answer 58

d. Tell me what it is about the injections that are concerning you.

Devote as much teaching time as possible to insulin injection and blood glucose monitoring. Clients with newly diagnosed diabetes are often fearful of giving themselves injections. If the client is worried about giving the injections, it is best to try to find out what specifically is causing the concern, so it can be addressed. Giving the injections for the client does not promote self-care ability. Telling the client that others give themselves injections may cause the client to feel bad. Stating that you don’t know another way to manage the disease is dismissive of the client’s concerns

Question 59

38. A nurse assesses a client with diabetes mellitus who self-administers subcutaneous insulin. The nurse notes
    a spongy, swelling area at the site the client uses most frequently for insulin injection. Which action should the
    nurse take?
    a. Apply ice to the site to reduce inflammation.
    b. Consult the provider for a new administration route.
    c. Assess the client for other signs of cellulitis.
    d. Instruct the client to rotate sites for insulin injection.

Answer 59

d. Instruct the client to rotate sites for insulin injection.

The clients tissue has been damaged from continuous use of the same site. The client should be educated to
rotate sites. The damaged tissue is not caused by cellulitis or any type infection, and applying ice may cause
more damage to the tissue. Insulin can only be administered subcutaneously and intravenously. It would not be appropriate or practical to change the administration route.

Question 60

40. After teaching a client who is newly diagnosed with type 2 diabetes mellitus, the nurse assesses the client’s
    understanding. Which statement made by the client indicates a need for additional teaching?
    a. I should increase my intake of vegetables with higher amounts of dietary fiber.
    b. My intake of saturated fats should be no more than 10% of my total calorie intake.
    c. I should decrease my intake of protein and eliminate carbohydrates from my diet.
    d. My intake of water is not restricted by my treatment plan or medication regimen.

Answer 60

c. I should decrease my intake of protein and eliminate carbohydrates from my diet.

The client should not completely eliminate carbohydrates from the diet, and should reduce protein if
microalbuminuria is present. The client should increase dietary intake of complex carbohydrates, including
vegetables, and decrease intake of fat. Water does not need to be restricted unless kidney failure is present.

Question 61

41. A nurse reviews laboratory results for a client with diabetes mellitus who is prescribed an intensified insulin regimen:
    Fasting blood glucose:
    75 mg/dL
    Postprandial blood glucose:
    200 mg/dL
    Hemoglobin A1c level:
    5.5%
    How should the nurse interpret these laboratory findings?
    a. Increased risk for developing ketoacidosis
    b. Good control of blood glucose
    c. Increased risk for developing hyperglycemia.
    d. Signs of insulin resistance

Answer 61

b. Good control of blood glucose

The client is maintaining blood glucose levels within the defined ranges for goals in an intensified regimen. Because the clients glycemic control is good, he or she is not at higher risk for ketoacidosis or hyperglycemia and is not showing signs of insulin resistance.

Question 62

42. A nurse prepares to administer insulin to a client at 1800. The client’s medication administration record contains the following information:
    Insulin glargine:
    12 units daily at 1800
    Regular insulin:
    6 units QID at 0600, 1200,
    1800, 2400
    Based on the client’s medication administration record, which action should the nurse take?
    a. Draw up and inject the insulin glargine first, and then draw up and inject the regular insulin.
    b. Draw up and inject the insulin glargine first, wait 20 minutes, and then draw up and inject the regular insulin.
    c. First draw up the dose of regular insulin, then draw up the dose of insulin glargine in the same syringe, mix, and inject the two insulins together.
    d. First draw up the dose of insulin glargine, then draw up the dose of regular insulin in the same syringe, mix, and inject the two insulins together.

Answer 62

a. Draw up and inject the insulin glargine first, and then draw up and inject the regular insulin.

Insulin glargine must not be diluted or mixed with any other insulin or solution. Mixing results in an
unpredictable alteration in the onset of action and time to peak action. The correct instruction is to draw up and
inject first the glargine and then the regular insulin right afterward.

Question 63

44. A nurse reviews the chart and new prescriptions for a client with diabetic ketoacidosis:
Vital Signs and Assessment:
BP: 90/62 mm Hg
Pulse: 120 beats/min
RR: 28 breaths/min
Urine output: 20 mL/hr via
catheter

Laboratory Results:
Serum K+: 2.6 mEq/L

Medications:

1) Potassium chloride 40 mEq IV bolus STAT
2) Increase IV fluid to 100 mL/hr

Which action should the nurse take?
a. Administer the potassium and then consult with the provider about the fluid order. b. Increase the intravenous rate and then consult with the provider about the potassium
prescription.
c. Administer the potassium first before increasing the infusion flow rate.
d. Increase the intravenous flow rate before administering the potassium.

Answer 63

b. Increase the intravenous rate and then consult with the provider about the potassium
prescription.

The client is acutely ill and is severely dehydrated and hypokalemic. The client requires more IV fluids and
potassium. However, potassium should not be infused unless the urine output is at least 30 mL/hr. The nurse should first increase the IV rate and then consult with the provider about the potassium.

Question 64

45. At 4:45 p.m., a nurse assesses a client with diabetes mellitus who is recovering from an abdominal hysterectomy 2 days ago. The nurse notes that the client is confused and diaphoretic. The nurse reviews the assessment data provided in the chart below:
Capillary Blood Glucose Testing (AC/HS):
At 0630: 95
At 1130: 70
At 1630: 47

Dietary Intake:
Breakfast: 10% eaten client states she is not hungry
Lunch: 5% eaten client is nauseous; vomits once

After reviewing the client’s assessment data, which action is appropriate at this time?

a. Assess the client’s oxygen saturation level and administer oxygen.
b. Reorient the client and apply a cool washcloth to the client’s forehead.
c. Administer dextrose 50% intravenously and reassess the client.
d. Provide a glass of orange juice and encourage the client to eat dinner.

Answer 64

c. Administer dextrose 50% intravenously and reassess the client.

The clients symptoms are related to hypoglycemia. Since the client has not been tolerating food, the nurse
should administer dextrose intravenously. The clients oxygen level could be checked, but based on the
information provided, this is not the priority. The client will not be reoriented until the glucose level rises.

Question 65

1. A nurse assesses clients at a health fair. Which clients should the nurse counsel to be tested for diabetes?
   (Select all that apply.)
   a. 56-year-old African-American male
   b. Female with a 30-pound weight gain during pregnancy
   c. Male with a history of pancreatic trauma
   d. A 48-year-old woman with a sedentary lifestyle
   e. Male with a BMI greater than 25 kg/m2
   f. 28-year-old female who gave birth to a baby weighing 9.2 pounds

Answer 65

a. 56-year-old African-American male
d. A 48-year-old woman with a sedentary lifestyle
e. Male with a BMI greater than 25 kg/m2
f. 28-year-old female who gave birth to a baby weighing 9.2 pounds

Risk factors for type 2 diabetes include certain ethnic/racial groups (African Americans, American Indians, Hispanics), obesity and physical inactivity, and giving birth to large babies. Pancreatic trauma and a 30-pound gestational weight gain are not risk factors.

Question 66

2. A nurse assesses a client who is experiencing diabetic ketoacidosis (DKA). For which manifestations should the nurse monitor the client? (Select all that apply.)
   a. Deep and fast respirations
   b. Decreased urine output
   c. Tachycardia
   d. Dependent pulmonary crackles
   e. Orthostatic hypotension

Answer 66

a. Deep and fast respirations
c. Tachycardia
e. Orthostatic hypotension

DKA leads to dehydration, which is manifested by tachycardia and orthostatic hypotension. Usually, clients have Kussmaul respirations, which are fast and deep. Increased urinary output (polyuria) is severe. Because of diuresis and dehydration, peripheral edema and crackles do not occur.

Question 67

3. A nurse teaches a client with diabetes mellitus about foot care. Which statements should the nurse include in this client’s teaching? (Select all that apply.)

a. Do not walk around barefoot.
b. Soak your feet in a tub each evening.
c. Trim toenails straight across with a nail clipper.
d. Treat any blisters or sores with Epsom salts.
e. Wash your feet every other day.

Answer 67

a. Do not walk around barefoot.
c. Trim toenails straight across with a nail clipper.

Clients who have diabetes mellitus are at high risk for wounds on the feet secondary to peripheral neuropathy and poor arterial circulation. The client should be instructed to not walk around barefoot or wear sandals with open toes. These actions place the client at higher risk for skin breakdown of the feet. The client should be instructed to trim toenails straight across with a nail clipper. Feet should be washed daily with lukewarm water and soap, but feet should not be soaked in the tub. The client should contact the provider immediately if blisters or sores appear and should not use home remedies to treat these wounds.

Question 68

4. A nurse provides diabetic education at a public health fair. Which disorders should the nurse include as complications of diabetes mellitus? 
(Select all that apply.)
a. Stroke
b. Kidney failure
c. Blindness
d. Respiratory failure
e. Cirrhosis

Answer 68

a. Stroke
b. Kidney failure
c. Blindness

Complications of diabetes mellitus are caused by macrovascular and microvascular changes. Macrovascular complications include coronary artery disease, cerebrovascular disease, and peripheral vascular disease. Microvascular complications include nephropathy, retinopathy, and neuropathy. Respiratory failure and
cirrhosis are not complications of diabetes mellitus.

Question 69

5. A nurse collaborates with the interdisciplinary team to develop a plan of care for a client who is newly diagnosed with diabetes mellitus. Which team members should the nurse include in this interdisciplinary team meeting? 
(Select all that apply.)
a. Registered dietitian
b. Clinical pharmacist
c. Occupational therapist
d. Health care provider
e. Speech-language pathologist

Answer 69

a. Registered dietitian
b. Clinical pharmacist
d. Health care provider

When planning care for a client newly diagnosed with diabetes mellitus, the nurse should collaborate with a
registered dietitian, clinical pharmacist, and health care provider. The focus of treatment for a newly diagnosed client would be nutrition, medication therapy, and education. The nurse could also consult with a diabetic educator. There is no need for occupational therapy or speech therapy at this time.

Question 70

Chapter 65: Assessment of the Renal/Urinary System

Answer 70

Drink some water, you’ve earned it.

Question 71

1. A nurse reviews the urinalysis of a client and notes the presence of glucose. Which action should the nurse take?
   a. Document findings and continue to monitor the client.
   b. Contact the provider and recommend a 24-hour urine test.
   c. Review the client’s recent dietary selections.
   d. Perform a capillary artery glucose assessment.

Answer 71

d. Perform a capillary artery glucose assessment.

Glucose normally is not found in the urine. The normal renal threshold for glucose is about 220 mg/dL, which means that a person whose blood glucose is less than 220 mg/dL will not have glucose in the urine. A positive finding for glucose on urinalysis indicates high blood sugar. The most appropriate action would be to perform a capillary artery glucose assessment. The client needs further evaluation for this abnormal result; therefore, documenting and continuing to monitor is not appropriate. Requesting a 24-hour urine test or reviewing the clients dietary selections will not assist the nurse to make a clinical decision related to this abnormality.

Question 72

5. A nurse contacts the health care provider after reviewing a client’s laboratory results and noting a blood urea nitrogen (BUN) of 35 mg/dL and a creatinine of 1.0 mg/dL. For which action should the nurse recommend a prescription?
   a. Intravenous fluids
   b. Hemodialysis
   c. Fluid restriction
   d. Urine culture and sensitivity

Answer 72

a. Intravenous fluids

Normal BUN is 10 to 20 mg/dL. Normal creatinine is 0.6 to 1.2 mg/dL (males) or 0.5 to 1.1 mg/dL (females). Creatinine is more specific for kidney function than BUN, because BUN can be affected by several factors (dehydration, high-protein diet, and catabolism). This clients creatinine is normal, which suggests a non-renal cause for the elevated BUN. A common cause of increased BUN is dehydration, so the nurse should anticipate giving the client more fluids, not placing the client on fluid restrictions. Hemodialysis is not an appropriate treatment for dehydration. The lab results do not indicate an infection; therefore, a urine culture and sensitivity is not appropriate.

Question 73

6. A nurse cares for a client with an increased blood urea nitrogen (BUN)/creatinine ratio. Which action should the nurse take first?
   a. Assess the client’s dietary habits.
   b. Inquire about the use of nonsteroidal anti-inflammatory drugs (NSAIDs).
   c. Hold the client’s metformin (Glucophage).
   d. Contact the health care provider immediately.

Answer 73

a. Assess the client’s dietary habits.

An elevated BUN/creatinine ratio is often indicative of dehydration, urinary obstruction, catabolism, or a high-protein diet. The nurse should inquire about the client’s dietary habits. Kidney damage related to NSAID use most likely would manifest with elevations in both BUN and creatinine, but no change in the ratio. The nurse should obtain more assessment data before holding any medications or contacting the provider.

Question 74

7. A nurse cares for a client with a urine specific gravity of 1.040. Which action should the nurse take?
   a. Obtain a urine culture and sensitivity.
   b. Place the client on restricted fluids.
   c. Assess the client’s creatinine level.
   d. Increase the client’s fluid intake.

Answer 74

d. Increase the client’s fluid intake.

Normal specific gravity for urine is 1.005 to 1.030. A high specific gravity can occur with dehydration, decreased kidney blood flow (often because of dehydration), and the presence of antidiuretic hormone. Increasing the client’s fluid intake would be a beneficial intervention. Assessing the creatinine or obtaining a urine culture would not provide data necessary for the nurse to make a clinical decision.

Question 75

8. A nurse reviews laboratory results for a client who was admitted for a myocardial infarction and cardiogenic shock 2 days ago. Which laboratory test result should the nurse expect to find?
   a. Blood urea nitrogen (BUN) of 52 mg/dL
   b. Creatinine of 2.3 mg/dL
   c. BUN of 10 mg/dL
   d. BUN/creatinine ratio of 8:1

Answer 75

a. Blood urea nitrogen (BUN) of 52 mg/dL

Shock leads to decreased renal perfusion. An elevated BUN accompanies this condition. The creatinine should be normal because no kidney damage occurred. A low BUN signifies overhydration, malnutrition, or liver damage. A low BUN/creatinine ratio indicates fluid volume excess or acute renal tubular acidosis.

Question 76

9. A nurse cares for a client with a urine specific gravity of 1.018. Which action should the nurse take?
   a. Evaluate the client’s intake and output for the past 24 hours.
   b. Document the finding in the chart and continue to monitor.
   c. Obtain a specimen for a urine culture and sensitivity.
   d. Encourage the client to drink more fluids, especially water.

Answer 76

b. Document the finding in the chart and continue to monitor.

This specific gravity is within the normal range for urine. There is no need to evaluate the client’s intake and output, obtain a urine specimen, or increase fluid intake.

Question 77

11. A nurse reviews a female client’s laboratory results. Which results from the client’s urinalysis should the nurse recognize as abnormal?
    a. pH 5.6
    b. Ketone bodies present
    c. Specific gravity of 1.020
    d. Clear and yellow color

Answer 77

b. Ketone bodies present

Ketone bodies are by-products of incomplete metabolism of fatty acids. Normally no ketones are present in urine. Ketone bodies are produced when fat sources are used instead of glucose to provide cellular energy. A pH between 4.6 and 8, specific gravity between 1.005 and 1.030, and clear yellow urine are normal findings for a female client’s urinalysis.

Question 78

12. A nurse reviews the allergy list of a client who is scheduled for an intravenous urography. Which client allergy should alert the nurse to urgently contact the health care provider?
    a. Seafood
    b. Penicillin
    c. Bee stings
    d. Red food dye

Answer 78

a. Seafood

Clients with seafood allergies often have severe allergic reactions to the standard dyes used during intravenous urography. The other allergies have no impact on the client’s safety during an intravenous urography.

Question 79

15. A nurse cares for a client who is recovering from a closed percutaneous kidney biopsy. The client states, My pain has suddenly increased from a 3 to a 10 on a scale of 0 to 10. Which action should the nurse take first?
    a. Reposition the client on the operative side.
    b. Administer the prescribed opioid analgesic.
    c. Assess the pulse rate and blood pressure.
    d. Examine the color of the client’s urine.

Answer 79

c. Assess the pulse rate and blood pressure.

An increase in the intensity of pain after a percutaneous kidney biopsy is a symptom of internal hemorrhage. A change in vital signs can indicate that hemorrhage is occurring. Before other actions, the nurse must assess the clients hemodynamic status.

Question 80

6. A nurse obtains a sterile urine specimen from a client’s Foley catheter. After applying a clamp to the drainage tubing distal to the injection port, which action should the nurse take next?
   a. Clamp another section of the tube to create a fixed sample section for retrieval.
   b. Insert a syringe into the injection port and aspirate the quantity of urine required.
   c. Clean the injection port cap of the drainage tubing with povidone-iodine solution.
   d. Withdraw 10 mL of urine and discard it; then withdraw a fresh sample of urine.

Answer 80

c. Clean the injection port cap of the drainage tubing with povidone-iodine solution.

It is important to clean the injection port cap of the catheter drainage tubing with an appropriate antiseptic, such as povidone-iodine solution or alcohol. This will help prevent surface contamination before injection of the syringe. The urine sample should be collected directly from the catheter; therefore, a second clamp to create a sample section would not be appropriate. Every sample from the catheter is usable; there is the need to discard the first sample.

Question 81

17. A nurse cares for a client who is having trouble voiding. The client states, “I cannot urinate in public places.” How should the nurse respond?
    a. I will turn on the faucet in the bathroom to help stimulate your urination.
    b. I can recommend a prescription for a diuretic to improve your urine output.
    c. I’ll move you to a room with a private bathroom to increase your comfort.
    d. I will close the curtain to provide you with as much privacy as possible.

Answer 81

d. I will close the curtain to provide you with as much privacy as possible.

The nurse should provide privacy to clients who may be uncomfortable or have issues related to elimination or the urogenital area. Turning on the faucet and administering a diuretic will not address the client’s concern. Although moving the client to a private room with a private bathroom would be nice, this is not realistic. The nurse needs to provide as much privacy as possible within the client’s current room.

Question 82

18. After delegating to an unlicensed assistive personnel (UAP) the task of completing a bladder scan examination for a client, the nurse evaluates the UAPs performance. Which action by the UAP indicates the nurse must provide additional instructions when delegating this task?
    a. Selecting the female icon for all female clients and male icon for all male clients
    b. Telling the client, This test measures the amount of urine in your bladder.
    c. Applying ultrasound gel to the scanning head and removing it when finished
    d. Taking at least two readings using the aiming icon to place the scanning head

Answer 82

a. Selecting the female icon for all female clients and male icon for all male clients

The UAP should use the female icon for women who have not had a hysterectomy. This allows the scanner to subtract the volume of the uterus from readings. If a woman has had a hysterectomy, the UAP should choose the male icon. The UAP should explain the procedure to the client, apply gel to the scanning head and clean it after use, and take at least two readings.

Question 83

2. A nurse assesses clients on the medical-surgical unit. Which clients are at risk for kidney problems?
   (Select all that apply.)
   a. A 24-year-old pregnant woman prescribed prenatal vitamins
   b. A 32-year-old bodybuilder taking synthetic creatine supplements
   c. A 56-year-old who is taking metformin for diabetes mellitus
   d. A 68-year-old taking high-dose nonsteroidal anti-inflammatory drugs (NSAIDs) for chronic back pain
   e. A 75-year-old with chronic obstructive pulmonary disease (COPD) who is prescribed an albuterol nebulizer

Answer 83

b. A 32-year-old bodybuilder taking synthetic creatine supplements.
c. A 56-year-old who is taking metformin for diabetes mellitus.
d. A 68-year-old taking high-dose nonsteroidal anti-inflammatory drugs (NSAIDs) for chronic back pain

Many medications can affect kidney function. Clients who take synthetic creatine supplements, metformin, and high-dose or long-term NSAIDs are at risk for kidney dysfunction. Prenatal vitamins and albuterol nebulizers do not place these clients at risk.

Question 84

3. A nurse assesses a client recovering from a cystoscopy. Which assessment findings should alert the nurse to urgently contact the health care provider? 
(Select all that apply.)
a. Decrease in urine output
b. Tolerating oral fluids
c. Prescription for metformin
d. Blood clots present in the urine
e. Burning sensation when urinating

Answer 84

a. Decrease in urine output
d. Blood clots present in the urine

The nurse should monitor urine output and contact the provider if urine output decreases or becomes absent. The nurse should also assess for blood in the clients urine. The urine may be pink-tinged, but gross bleeding or blood clots should not be present. If bleeding is present, the nurse should urgently contact the provider. Tolerating oral fluids is a positive outcome and does not need intervention. Metformin would be a concern if the client received dye; no dye is used in a cystoscopy procedure. The client may experience a burning sensation when urinating after this procedure; this would not require a call to the provider.

Question 85

4. A nurse prepares a client for a percutaneous kidney biopsy. Which actions should the nurse take prior to this procedure? (Select all that apply.)
   a. Keep the client NPO for 4 to 6 hours.
   b. Obtain coagulation study results.
   c. Maintain strict bed rest in a supine position.
   d. Assess for blood in the client’s urine.
   e. Administer antihypertensive medications.

Answer 85

a. Keep the client NPO for 4 to 6 hours.
b. Obtain coagulation study results.
e. Administer antihypertensive medications.

Prior to a percutaneous kidney biopsy, the client should be NPO for 4 to 6 hours. Coagulation studies should be completed to prevent bleeding after the biopsy. Blood pressure medications should be administered to prevent hypertension before and after the procedure. There is no need to keep the client on bed rest or assess for blood in the client’s urine prior to the procedure; these interventions should be implemented after a percutaneous kidney biopsy.

Question 86

5. A nurse plans care for an older adult client. Which interventions should the nurse include in this client’s plan of care to promote kidney health? (Select all that apply.)
   a. Ensure adequate fluid intake.
   b. Leave the bathroom light on at night.
   c. Encourage use of the toilet every 6 hours.
   d. Delegate bladder training instructions to the unlicensed assistive personnel (UAP).
   e. Provide thorough perineal care after each voiding.
   f. Assess for urinary retention and urinary tract infection.

Answer 86

a. Ensure adequate fluid intake.
b. Leave the bathroom light on at night.
e. Provide thorough perineal care after each voiding.
f. Assess for urinary retention and urinary tract infection.

The nurse should ensure that the client receives adequate fluid intake and has adequate lighting to ambulate safely to the bathroom at night, encourage the client to use the toilet every 2 hours, provide thorough perineal care after each voiding, and assess for urinary retention and urinary tract infections. The nurse should not delegate any teaching to the UAP, including bladder training instructions. The UAP may participate in bladder training activities, including encouraging and assisting the client to the bathroom at specific times.

Question 87

Chapter 66: Care of Patients with Urinary Problems

Answer 87

Gotta go, gotta go, gotta go right now

Question 88

1. A nurse assesses clients on the medical-surgical unit. Which client is at the greatest risk for the development of bacterial cystitis?
   a. A 36-year-old female who has never been pregnant
   b. A 42-year-old male who is prescribed cyclophosphamide
   c. A 58-year-old female who is not taking estrogen replacement
   d. A 77-year-old male with mild congestive heart failure

Answer 88

c. A 58-year-old female who is not taking estrogen replacement

Females at any age are more susceptible to cystitis than men because of the shorter urethra in women. Postmenopausal women who are not on hormone replacement therapy are at increased risk for bacterial cystitis because of changes in the cells of the urethra and vagina. The middle-aged woman who has never been pregnant would not have a risk potential as high as the older woman who is not using hormone replacement therapy.

Question 89

2. A nurse reviews the laboratory findings of a client with a urinary tract infection. The laboratory report notes a shift to the left in a client’s white blood cell count. Which action should the nurse take?
   a. Request that the laboratory perform a differential analysis on the white blood cells.
   b. Notify the provider and start an intravenous line for parenteral antibiotics.
   c. Collaborate with the unlicensed assistive personnel (UAP) to strain the client’s urine for renal calculi.
   d. Assess the client for a potential allergic reaction and anaphylactic shock.

Answer 89

b. Notify the provider and start an intravenous line for parenteral antibiotics.

An increase in band cells creates a shift to the left. A left shift most commonly occurs with urosepsis and is seen rarely with uncomplicated urinary tract infections. The nurse will be administering antibiotics, most likely via IV, so he or she should notify the provider and prepare to give the antibiotics. The shift to the left is part of a differential white blood cell count. The nurse would not need to strain urine for stones. Allergic reactions are associated with elevated eosinophil cells, not band cells.

Question 90

3. A nurse cares for a postmenopausal client who has had two episodes of bacterial urethritis in the last 6 months. The client asks, I never have urinary tract infections. Why is this happening now? How should the nurse respond?
   a. Your immune system becomes less effective as you age.
   b. Low estrogen levels can make the tissue more susceptible to infection.
   c. You should be more careful with your personal hygiene in this area.
   d. It is likely that you have an untreated sexually transmitted disease.

Answer 90

b. Low estrogen levels can make the tissue more susceptible to infection.

Low estrogen levels decrease moisture and secretions in the perineal area and cause other tissue changes, predisposing it to the development of infection. Urethritis is most common in postmenopausal women for this reason. Although immune function does decrease with aging and sexually transmitted diseases are a known cause of urethritis, the most likely reason in this client is low estrogen levels. Personal hygiene usually does not contribute to this disease process.

Question 91

5. After teaching a client who has stress incontinence, the nurse assesses the client’s understanding. Which statement made by the client indicates a need for additional teaching?
   a. I will limit my total intake of fluids.
   b. I must avoid drinking alcoholic beverages.
   c. I must avoid drinking caffeinated beverages.
   d. I shall try to lose about 10% of my body weight.

Answer 91

a. I will limit my total intake of fluids.

Limiting fluids concentrates urine and can irritate tissues, leading to increased incontinence. Many people try to manage incontinence by limiting fluids. Alcoholic and caffeinated beverages are bladder stimulants. Obesity increases intra-abdominal pressure, causing incontinence.

Question 92

6. A nurse cares for adult clients who experience urge incontinence. For which client should the nurse plan a habit training program?
   a. A 78-year-old female who is confused
   b. A 65-year-old male with diabetes mellitus
   c. A 52-year-old female with kidney failure
   d. A 47-year-old male with arthritis

Answer 92

a. A 78-year-old female who is confused

For a bladder training program to succeed in a client with urge incontinence, the client must be alert, aware, and able to resist the urge to urinate. Habit training will work best for a confused client. This includes going to the bathroom (or being assisted to the bathroom) at set times. The other clients may benefit from another type of bladder training.

Question 93

7. After delegating care to an unlicensed assistive personnel (UAP) for a client who is prescribed habit training to manage incontinence, a nurse evaluates the UAPs understanding. Which action indicates the UAP needs additional teaching?
   a. Toileting the client after breakfast
   b. Changing the client’s incontinence brief when wet
   c. Encouraging the client to drink fluids
   d. Recording the client’s incontinence episodes

Answer 93

b. Changing the client’s incontinence brief when wet

Habit training is undermined by the use of absorbent incontinence briefs or pads. The nurse should re-educate the UAP on the technique of habit training. The UAP should continue to toilet the client after meals, encourage the client to drink fluids, and record incontinent episodes.

Question 94

8. A nurse plans care for a client with overflow incontinence. Which intervention should the nurse include in this client’s plan of care to assist with elimination?
   a. Stroke the medial aspect of the thigh.
   b. Use intermittent catheterization.
   c. Provide digital anal stimulation.
   d. Use the Valsalva maneuver.

Answer 94

d. Use the Valsalva maneuver.

In clients with overflow incontinence, the voiding reflex arc is not intact. Mechanical pressure, such as that achieved through the Valsalva maneuver (holding the breath and bearing down as if to defecate), can initiate voiding. Stroking the medial aspect of the thigh or providing digital anal stimulation requires the reflex arc to be intact to initiate elimination. Due to the high risk for infection, intermittent catheterization should only be implemented when other interventions are not successful.

Question 95

9. A confused client with pneumonia is admitted with an indwelling catheter in place. During interdisciplinary rounds the following day, which question should the nurse ask the primary health care provider?
   a. Do you want daily weights on this client?
   b. Will the client be able to return home?
   c. Can we discontinue the indwelling catheter?
   d. Should we get another chest x-ray today?

Answer 95

c. Can we discontinue the indwelling catheter?

An indwelling catheter dramatically increases the risks of urinary tract infection and urosepsis. Nursing staff should ensure that catheters are left in place only as long as they are medically needed. The nurse should inquire about removing the catheter. All other questions might be appropriate, but because of client safety, this question takes priority.

Question 96

10. After teaching a client with a history of renal calculi, the nurse assesses the client’s understanding. Which statement made by the client indicates a correct understanding of the teaching?
    a. I should drink at least 3 liters of fluid every day.
    b. I will eliminate all dairy or sources of calcium from my diet.
    c. Aspirin and aspirin-containing products can lead to stones.
    d. The doctor can give me antibiotics at the first sign of a stone.

Answer 96

a. I should drink at least 3 liters of fluid every day.

Dehydration contributes to the precipitation of minerals to form a stone. Although increased intake of calcium causes hypercalcemia and leads to excessive calcium filtered into the urine, if the client is well hydrated the calcium will be excreted without issues. Dehydration increases the risk for supersaturation of calcium in the urine, which contributes to stone formation. The nurse should encourage the client to drink more fluids, not decrease calcium intake. Ingestion of aspirin or aspirin-containing products does not cause a stone. Antibiotics neither prevent nor treat a stone.

Question 97

12. A nurse assesses a client who is recovering from extracorporeal shock wave lithotripsy for renal calculi. The nurse notes an ecchymotic area on the client’s right lower back. Which action should the nurse take?
    a. Administer fresh-frozen plasma.
    b. Apply an ice pack to the site.
    c. Place the client in the prone position.
    d. Obtain serum coagulation test results.

Answer 97

b. Apply an ice pack to the site.

The shock waves from lithotripsy can cause bleeding into the tissues through which the waves pass. Application of ice can reduce the extent and discomfort of the bruising. Although coagulation test results and fresh-frozen plasma are used to assess and treat bleeding disorders, ecchymosis after this procedure is not unusual and does not warrant a higher level of intervention. Changing the clients position will not decrease bleeding.

Question 98

13. A nurse cares for a client admitted from a nursing home after several recent falls. What prescription should the nurse complete first?
    a. Obtain urine sample for culture and sensitivity.
    b. Administer intravenous antibiotics.
    c. Encourage protein intake and additional fluids.
    d. Consult physical therapy for gait training.

Answer 98

a. Obtain urine sample for culture and sensitivity.

Although all interventions are or might be important, obtaining a urine sample for urinalysis takes priority. Often urinary tract infection (UTI) symptoms in older adults are atypical, and a UTI may present with new onset of confusion or falling. The urine sample should be obtained before starting antibiotics. Dietary requirements and gait training should be implemented after obtaining the urine sample.

Question 99

16. A nurse obtains the health history of a client with a suspected diagnosis of bladder cancer. Which question should the nurse ask when determining this client’s risk factors?
    a. Do you smoke cigarettes?
    b. Do you use any alcohol?
    c. Do you use recreational drugs?
    d. Do you take any prescription drugs?

Answer 99

a. Do you smoke cigarettes?

Smoking is known to be a factor that greatly increases the risk of bladder cancer. Alcohol use, recreational drug use, and prescription drug use (except medications that contain phenacetin) are not known to increase the risk of developing bladder cancer.

Question 100

19. A nurse teaches a client with functional urinary incontinence. Which statement should the nurse include in this client’s teaching?
    a. You must clean around your catheter daily with soap and water.
    b. Wash the vaginal weights with a 10% bleach solution after each use.
    c. Operations to repair your bladder are available, and you can consider these.
    d. Buy slacks with elastic waistbands that are easy to pull down.

Answer 100

d. Buy slacks with elastic waistbands that are easy to pull down.

Functional urinary incontinence occurs as the result of problems not related to the clients bladder, such as trouble ambulating or difficulty accessing the toilet. One goal is that the client will be able to manage his or her clothing independently. Elastic waistband slacks that are easy to pull down can help the client get on the toilet in time to void. The other instructions do not relate to functional urinary incontinence.

Question 101

21. A nurse teaches a client who is starting urinary bladder training. Which statement should the nurse include in this client’s teaching?
    a. Use the toilet when you first feel the urge, rather than at specific intervals.
    b. Try to consciously hold your urine until the scheduled toileting time.
    c. Initially try to use the toilet at least every half hour for the first 24 hours.
    d. The toileting interval can be increased once you have been continent for a week.

Answer 101

b. Try to consciously hold your urine until the scheduled toileting time.

The client should try to hold the urine consciously until the next scheduled toileting time. Toileting should occur at specific intervals during the training. The toileting interval should be no less than every hour. The interval can be increased once the client becomes comfortable with the interval.

Question 102

22. A nurse plans care for clients with urinary incontinence. Which client is correctly paired with the appropriate intervention?
    a. A 29-year-old client after a difficult vaginal delivery Habit training
    b. A 58-year-old postmenopausal client who is not taking estrogen therapy Electrical stimulation
    c. A 64-year-old female with Alzheimers-type senile dementia Bladder training
    d. A 77-year-old female who has difficulty ambulating Exercise therapy

Answer 102

b. A 58-year-old postmenopausal client who is not taking estrogen therapy Electrical stimulation

Exercise therapy and electrical stimulation are used for clients with stress incontinence related to childbirth or low levels of estrogen after menopause. Exercise therapy increases pelvic wall strength; it does not improve ambulation. Physical therapy and a bedside commode would be appropriate interventions for the client who has difficulty ambulating. Habit training is the type of bladder training that will be most effective with cognitively impaired clients. Bladder training can be used only with a client who is alert, aware, and able to resist the urge to urinate.

Question 103

23. A nurse assesses a client who presents with renal calculi. Which question should the nurse ask?
    a. Do any of your family members have this problem?
    b. Do you drink any cranberry juice?
    c. Do you urinate after sexual intercourse?
    d. Do you experience burning with urination?

Answer 103

a. Do any of your family members have this problem?

There is a strong association between family history and stone formation and recurrence. Nephrolithiasis is associated with many genetic variations; therefore, the nurse should ask whether other family members have also had renal stones. The other questions do not refer to renal calculi but instead are questions that should be asked of a client with a urinary tract infection.

Question 104

24. A nurse assesses a male client who is recovering from a urologic procedure. Which assessment finding indicates an obstruction of urine flow?
    a. Severe pain
    b. Overflow incontinence
    c. Hypotension
    d. Blood-tinged urine

Answer 104

b. Overflow incontinence

The most common manifestation of urethral stricture after a urologic procedure is obstruction of urine flow. This rarely causes pain and has no impact on blood pressure. The client may experience overflow incontinence with the involuntary loss of urine when the bladder is distended. Blood in the urine is not a manifestation of the obstruction of urine flow.

Question 105

25. A nurse cares for a client with urinary incontinence. The client states, “I am so embarrassed. My bladder leaks like a young child’s bladder.” How should the nurse respond?
    a. I understand how you feel. I would be mortified.
    b. Incontinence pads will minimize leaks in public.
    c. I can teach you strategies to help control your incontinence.
    d. More women experience incontinence than you might think.

Answer 105

c. I can teach you strategies to help control your incontinence.

The nurse should accept and acknowledge the clients concerns, and assist the client to learn techniques that will allow control of urinary incontinence. The nurse should not diminish the clients concerns with the use of pads or stating statistics about the occurrence of incontinence.

Question 106

26. A nurse provides phone triage to a pregnant client. The client states, “I am experiencing a burning pain when I urinate.” How should the nurse respond?
    a. This means labor will start soon. Prepare to go to the hospital.
    b. You probably have a urinary tract infection. Drink more cranberry juice.
    c. Make an appointment with your provider to have your infection treated.
    d. Your pelvic wall is weakening. Pelvic muscle exercises should help.

Answer 106

c. Make an appointment with your provider to have your infection treated.

Pregnant clients with a urinary tract infection require prompt and aggressive treatment because cystitis can lead to acute pyelonephritis during pregnancy. The nurse should encourage the client to make an appointment and have the infection treated. Burning pain when urinating does not indicate the start of labor or weakening of pelvic muscles.

Question 107

1. A nurse assesses a client who has had two episodes of bacterial cystitis in the last 6 months. Which questions should the nurse ask?
   (Select all that apply.)
   a. How much water do you drink every day?
   b. Do you take estrogen replacement therapy?
   c. Does anyone in your family have a history of cystitis?
   d. Are you on steroids or other immune-suppressing drugs?
   e. Do you drink grapefruit juice or orange juice daily?

Answer 107

a. How much water do you drink every day?
b. Do you take estrogen replacement therapy?
d. Are you on steroids or other immune-suppressing drugs?

Fluid intake, estrogen levels, and immune suppression all can increase the chance of recurrent cystitis. Family history is usually insignificant, and cranberry juice, not grapefruit or orange juice, has been found to increase the acidic pH and reduce the risk for bacterial cystitis.

Question 108

2. A nurse teaches a client about self-catheterization in the home setting. Which statements should the nurse include in this client’s teaching?
   (Select all that apply.)
   a. Wash your hands before and after self-catheterization.
   b. Use a large-lumen catheter for each catheterization.
   c. Use lubricant on the tip of the catheter before insertion.
   d. Self-catheterize at least twice a day or every 12 hours.
   e. Use sterile gloves and sterile technique for the procedure.
   f. Maintain a specific schedule for catheterization.

Answer 108

a. Wash your hands before and after self-catheterization.
c. Use lubricant on the tip of the catheter before insertion.
f. Maintain a specific schedule for catheterization.

The key points in self-catheterization include washing hands, using lubricants, and maintaining a regular schedule to avoid distention and retention of urine that leads to bacterial growth. A smaller rather than a larger lumen catheter is preferred. The client needs to catheterize more often than every 12 hours. Self-catheterization in the home is a clean procedure.

Question 109

3. A nurse teaches clients about the difference between urge incontinence and stress incontinence. Which statements should the nurse include in this education? (Select all that apply.)
   a. Urge incontinence involves a post-void residual volume less than 50 mL.
   b. Stress incontinence occurs due to weak pelvic floor muscles.
   c. Stress incontinence usually occurs in people with dementia.
   d. Urge incontinence can be managed by increasing fluid intake.
   e. Urge incontinence occurs due to abnormal bladder contractions.

Answer 109

b. Stress incontinence occurs due to weak pelvic floor muscles.
e. Urge incontinence occurs due to abnormal bladder contractions.

Clients who suffer from stress incontinence have weak pelvic floor muscles or urethral sphincter and cannot tighten their urethra sufficiently to overcome the increased detrusor pressure. Stress incontinence is common after childbirth, when the pelvic muscles are stretched and weakened from pregnancy and delivery. Urge incontinence occurs in people who cannot suppress the contraction signal from the detrusor muscle. Abnormal detrusor contractions may be a result of neurologic abnormalities including dementia, or may occur with no known abnormality. Post-void residual is associated with reflex incontinence, not with urge incontinence or stress incontinence. Management of urge incontinence includes decreasing fluid intake, especially in the evening hours.

Question 110

4. A nurse assesses a client with a fungal urinary tract infection (UTI). Which assessments should the nurse complete?
   (Select all that apply.)
   a. Palpate the kidneys and bladder.
   b. Assess the medical history and current medical problems.
   c. Perform a bladder scan to assess post-void residual.
   d. Inquire about recent travel to foreign countries.
   e. Obtain a current list of medications.

Answer 110

b. Assess the medical history and current medical problems.
e. Obtain a current list of medications.

Clients who are severely immunocompromised or who have diabetes mellitus are more prone to fungal UTIs. The nurse should assess for these factors by asking about medical history, current medical problems, and the current medication list. A physical examination and a post-void residual may be needed, but not until further information is obtained indicating that these examinations are necessary. Travel to foreign countries probably would not be important because, even if exposed, the client needs some degree of compromised immunity to develop a fungal UTI.

Question 111

5. A nurse cares for clients with urinary incontinence. Which types of incontinence are correctly paired with their clinical manifestation?
   (Select all that apply.)
   a. Stress incontinence Urine loss with physical exertion
   b. Urge incontinence Large amount of urine with each occurrence
   c. Functional incontinence Urine loss results from abnormal detrusor contractions
   d. Overflow incontinence Constant dribbling of urine
   e. Reflex incontinence Leakage of urine without lower urinary tract disorder

Answer 111

a. Stress incontinence Urine loss with physical exertion
b. Urge incontinence Large amount of urine with each occurrence
d. Overflow incontinence Constant dribbling of urine

Stress incontinence is a loss of urine with physical exertion, coughing, sneezing, or exercising.
Urge incontinence presents with an abrupt and strong urge to void and usually has a large amount of urine released with each occurrence.
Overflow incontinence occurs with bladder distention and results in a constant dribbling of urine.
Functional incontinence is the leakage of urine caused by factors other than a disorder of the lower urinary tract. Reflex incontinence results from abnormal detrusor contractions from a neurologic abnormality.

Question 112

6. A nurse teaches a client with a history of calcium phosphate urinary stones. Which statements should the nurse include in this client’s dietary teaching? (Select all that apply.)
   a. Limit your intake of food high in animal protein.
   b. Read food labels to help minimize your sodium intake.
   c. Avoid spinach, black tea, and rhubarb.
   d. Drink white wine or beer instead of red wine.
   e. Reduce your intake of milk and other dairy products.

Answer 112

a. Limit your intake of food high in animal protein.
b. Read food labels to help minimize your sodium intake.
e. Reduce your intake of milk and other dairy products.

Clients with calcium phosphate urinary stones should be taught to limit the intake of foods high in animal protein, sodium, and calcium. Clients with calcium oxalate stones should avoid spinach, black tea, and rhubarb. Clients with uric acid stones should avoid red wine.

Question 113

7. A nurse teaches a client about self-care after experiencing a urinary calculus treated by lithotripsy. Which statements should the nurse include in this client’s discharge teaching? (
   Select all that apply.)
   a. Finish the prescribed antibiotic even if you are feeling better.
   b. Drink at least 3 liters of fluid each day.
   c. The bruising on your back may take several weeks to resolve.
   d. Report any blood present in your urine.
   e. It is normal to experience pain and difficulty urinating.

Answer 113

a. Finish the prescribed antibiotic even if you are feeling better.
b. Drink at least 3 liters of fluid each day.
c. The bruising on your back may take several weeks to resolve.

The client should be taught to finish the prescribed antibiotic to ensure that he or she does not get a urinary tract infection. The client should drink at least 3 liters of fluid daily to dilute potential stone-forming crystals, prevent dehydration, and promote urine flow. After lithotripsy, the client should expect bruising that may take several weeks to resolve. The client should also experience blood in the urine for several days. The client should report any pain, fever, chills, or difficulty with urination to the provider as these may signal the beginning of an infection or the formation of another stone.

Question 114

8. A nurse teaches a female client who has stress incontinence. Which statements should the nurse include about pelvic muscle exercises? (Select all that apply.)
   a. When you start and stop your urine stream, you are using your pelvic muscles.
   b. Tighten your pelvic muscles for a slow count of 10 and then relax for a slow count of 10.
   c. Pelvic muscle exercises should only be performed sitting upright with your feet on the floor.
   d. After you have been doing these exercises for a couple days, your control of urine will improve.
   e. Like any other muscle in your body, you can make your pelvic muscles stronger by contracting them.

Answer 114

a. When you start and stop your urine stream, you are using your pelvic muscles.
b. Tighten your pelvic muscles for a slow count of 10 and then relax for a slow count of 10.
e. Like any other muscle in your body, you can make your pelvic muscles stronger by contracting them.

The client should be taught that the muscles used to start and stop urination are pelvic muscles, and that pelvic muscles can be strengthened by contracting and relaxing them. The client should tighten pelvic muscles for a slow count of 10 and then relax the muscles for a slow count of 10, and perform this exercise 15 times while in lying-down, sitting-up, and standing positions. The client should begin to notice improvement in control of urine after several weeks of exercising the pelvic muscles.

Question 115

Chapter 67: Care of Patients with Kidney Disorders

Answer 115

It never eeeeends

Question 116

1. A nurse assesses a client with polycystic kidney disease (PKD). Which assessment finding should alert the nurse to immediately contact the health care provider?
   a. Flank pain
   b. Periorbital edema
   c. Bloody and cloudy urine
   d. Enlarged abdomen

Answer 116

b. Periorbital edema

Periorbital edema would not be a finding related to PKD and should be investigated further. Flank pain and a distended or enlarged abdomen occur in PKD because the kidneys enlarge and displace other organs. Urine can be bloody or cloudy as a result of cyst rupture or infection.

Question 117

2. A nurse cares for a client with autosomal dominant polycystic kidney disease (ADPKD). The client asks, Will my children develop this disease? How should the nurse respond?
   a. No genetic link is known, so your children are not at increased risk.
   b. Your sons will develop this disease because it has a sex-linked gene.
   c. Only if both you and your spouse are carriers of this disease.
   d. Each of your children has a 50% risk of having ADPKD.

Answer 117

d. Each of your children has a 50% risk of having ADPKD.

Children whose parent has the autosomal dominant form of PKD have a 50% chance of inheriting the gene that causes the disease. ADPKD is transmitted as an autosomal dominant trait and therefore is not gender-specific. Both parents do not need to have this disorder.

Question 118

3. After teaching a client with early polycystic kidney disease (PKD) about nutritional therapy, the nurse assesses the client’s understanding. Which statement made by the client indicates a correct understanding of the teaching?
   a. I will take a laxative every night before going to bed.
   b. I must increase my intake of dietary fiber and fluids.
   c. I shall only use salt when I am cooking my own food.
   d. I’ll eat white bread to minimize gastrointestinal gas.

Answer 118

b. I must increase my intake of dietary fiber and fluids.

Clients with PKD often have constipation, which can be managed with increased fiber, exercise, and drinking plenty of water. Laxatives should be used cautiously. Clients with PKD should be on a restricted salt diet, which includes not cooking with salt. White bread has a low fiber count and would not be included in a high-fiber diet.

Question 119

4. A nurse cares for a middle-aged female client with diabetes mellitus who is being treated for the third episode of acute pyelonephritis in the past year. The client asks, What can I do to help prevent these infections? How should the nurse respond?
   a. Test your urine daily for the presence of ketone bodies and proteins.
   b. Use tampons rather than sanitary napkins during your menstrual period.
   c. Drink more water and empty your bladder more frequently during the day.
   d. Keep your hemoglobin A1c under 9% by keeping your blood sugar controlled.

Answer 119

c. Drink more water and empty your bladder more frequently during the day.

Clients with long-standing diabetes mellitus are at risk for pyelonephritis for many reasons. Chronically elevated blood glucose levels spill glucose into the urine, changing the pH and providing a favorable climate for bacterial growth. The neuropathy associated with diabetes reduces bladder tone and reduces the clients sensation of bladder fullness. Thus, even with large amounts of urine, the client voids less frequently, allowing stasis and overgrowth of microorganisms. Increasing fluid intake (specifically water) and voiding frequently prevent stasis and bacterial overgrowth. Testing urine and using tampons will not help prevent pyelonephritis. A hemoglobin A1c of 9% is too high.

Question 120

5. A nurse evaluates a client with acute glomerulonephritis (GN). Which manifestation should the nurse recognize as a positive response to the prescribed treatment?
   a. The client has lost 11 pounds in the past 10 days.
   b. The client’s urine specific gravity is 1.048.
   c. No blood is observed in the client’s urine.
   d. The client’s blood pressure is 152/88 mm Hg.

Answer 120

a. The client has lost 11 pounds in the past 10 days.

Fluid retention is a major feature of acute GN. This weight loss represents fluid loss, indicating that the glomeruli are performing the function of filtration. A urine specific gravity of 1.048 is high. Blood is not usually seen in GN, so this finding would be expected. A blood pressure of 152/88 mm Hg is too high; this may indicate kidney damage or fluid overload.

Question 121

6. After teaching a client with nephrotic syndrome and a normal glomerular filtration, the nurse assesses the client’s understanding. Which statement made by the client indicates a correct understanding of the nutritional therapy for this condition?
   a. I must decrease my intake of fat.
   b. I will increase my intake of protein.
   c. A decreased intake of carbohydrates will be required.
   d. An increased intake of vitamin C is necessary.

Answer 121

b. I will increase my intake of protein.

In nephrotic syndrome, the renal loss of protein is significant, leading to hypoalbuminemia and edema formation. If glomerular filtration is normal or near normal, increased protein loss should be matched by increased intake of protein. The client would not need to adjust fat, carbohydrates, or vitamins based on this disorder.

Question 122

7. A nurse assesses a client who is recovering from a radical nephrectomy for renal cell carcinoma. The nurse notes that the client’s blood pressure has decreased from 134/90 to 100/56 mm Hg and urine output is 20 mL for this past hour. Which action should the nurse take?
   a. Position the client to lay on the surgical incision.
   b. Measure the specific gravity of the client’s urine.
   c. Administer intravenous pain medications.
   d. Assess the rate and quality of the client’s pulse.

Answer 122

d. Assess the rate and quality of the client’s pulse.

The nurse should first fully assess the client for signs of volume depletion and shock, and then notify the provider. The radical nature of the surgery and the proximity of the surgery to the adrenal gland put the client at risk for hemorrhage and adrenal insufficiency. Hypotension is a clinical manifestation associated with both hemorrhage and adrenal insufficiency. Hypotension is particularly dangerous for the remaining kidney, which must receive adequate perfusion to function effectively. Re-positioning the client, measuring specific gravity, and administering pain medication would not provide data necessary to make an appropriate clinical decision, nor are they appropriate interventions at this time.

Question 123

8. An emergency department nurse assesses a client with kidney trauma and notes that the client’s abdomen is tender and distended and blood is visible at the urinary meatus. Which prescription should the nurse consult the provider about before implementation?
   a. Assessing vital signs every 15 minutes
   b. Inserting an indwelling urinary catheter
   c. Administering intravenous fluids at 125 mL/hr
   d. Typing and crossmatching for blood products

Answer 123

b. Inserting an indwelling urinary catheter

Clients with blood at the urinary meatus should not have a urinary catheter inserted via the urethra before additional diagnostic studies are done. The urethra could be torn. The nurse should question the provider about the need for a catheter; if one is needed, the provider can insert a suprapubic catheter. The nurse should monitor the client’s vital signs closely, send blood for type and crossmatch in case the client needs blood products, and administer intravenous fluids.

Question 124

9. After teaching a client with hypertension secondary to renal disease, the nurse assesses the client’s understanding. Which statement made by the client indicates a need for additional teaching?
   a. I can prevent more damage to my kidneys by managing my blood pressure.
   b. If I have increased urination at night, I need to drink less fluid during the day.
   c. I need to see the registered dietitian to discuss limiting my protein intake.
   d. It is important that I take my antihypertensive medications as directed.

Answer 124

b. If I have increased urination at night, I need to drink less fluid during the day.

The client should not restrict fluids during the day due to increased urination at night. Clients with renal disease may be prescribed fluid restrictions. These clients should be assessed thoroughly for potential dehydration. Increased nocturnal voiding can be decreased by consuming fluids earlier in the day. Blood pressure control is needed to slow the progression of renal dysfunction. When dietary protein is restricted, refer the client to the registered dietitian as needed.

Question 125

10. A nurse cares for a client who is recovering after a nephrostomy tube was placed 6 hours ago. The nurse notes drainage in the tube has decreased from 40 mL/hr to 12 mL over the last hour. Which action should the nurse take?
    a. Document the finding in the client’s record.
    b. Evaluate the tube as working in the hand-off report. c. Clamp the tube in preparation for removing it.
    d. Assess the client’s abdomen and vital signs.

Answer 125

d. Assess the client’s abdomen and vital signs.

The nephrostomy tube should continue to have a consistent amount of drainage. If the drainage slows or stops, it may be obstructed. The nurse must notify the provider, but first should carefully assess the client’s abdomen for pain and distention and check vital signs so that this information can be reported as well. The other interventions are not appropriate.

Question 126

12. A nurse provides health screening for a community health center with a large population of African- American clients. Which priority assessment should the nurse include when working with this population?
    a. Measure height and weight.
    b. Assess blood pressure.
    c. Observe for any signs of abuse.
    d. Ask about medications.

Answer 126

b. Assess blood pressure.

All interventions are important for the visiting nurse to accomplish. However, African Americans have a high rate of hypertension leading to end-stage renal disease. Each encounter that the nurse has with an African- American client provides a chance to detect hypertension and treat it. If the client is already on antihypertensive medication, assessing blood pressure monitors therapy.

Question 127

14. A nurse cares for a client who has pyelonephritis. The client states, “I am embarrassed to talk about my symptoms.” How should the nurse respond?
    a. I am a professional. Your symptoms will be kept in confidence.
    b. I understand. Elimination is a private topic and shouldn’t be discussed.
    c. Take your time. It is okay to use words that are familiar to you.
    d. You seem anxious. Would you like a nurse of the same gender to care for you?

Answer 127

c. Take your time. It is okay to use words that are familiar to you.

Clients may be uncomfortable discussing issues related to elimination and the genitourinary area. The nurse should encourage the client to use language that is familiar to the client. The nurse should not make promises that cannot be kept, like keeping the clients symptoms confidential. The nurse must assess the client and cannot take the time to stop the discussion or find another nurse to complete the assessment.

Question 128

1. A nurse assesses a client who has a family history of polycystic kidney disease (PKD). For which clinical manifestations should the nurse assess? 
(Select all that apply.)
a. Nocturia
b. Flank pain
c. Increased abdominal girth 
d. Dysuria
e. Hematuria
f. Diarrhea

Answer 128

b. Flank pain
c. Increased abdominal girth
e. Hematuria

Clients with PKD experience abdominal distention that manifests as flank pain and increased abdominal girth. Bloody urine is also present with tissue damage secondary to PKD. Clients with PKD often experience constipation, but would not report nocturia or dysuria.

Question 129

2. A nurse assesses a client with nephrotic syndrome. For which clinical manifestations should the nurse assess? (Select all that apply.)
   a. Proteinuria
   b. Hypoalbuminemia
   c. Dehydration
   d. Lipiduria
   e. Dysuria
   f. Costovertebral angle (CVA) tenderness

Answer 129

a. Proteinuria
b. Hypoalbuminemia
d. Lipiduria

Nephrotic syndrome is caused by glomerular damage and is characterized by proteinuria (protein level higher than 3.5 g/24 hr), hypoalbuminemia, edema, and lipiduria. Fluid overload leading to edema and hypertension is common with nephrotic syndrome; dehydration does not occur. Dysuria is present with cystitis. CVA tenderness is present with inflammatory changes in the kidney.

Question 130

3. A nurse reviews laboratory results for a client with glomerulonephritis. The client's glomerular filtration rate (GFR) is 40 mL/min as measured by a 24-hour creatinine clearance. How should the nurse interpret this finding? 
(Select all that apply.)
a. Excessive GFR
b. Normal GFR
c. Reduced GFR
d. Potential for fluid overload 
e. Potential for dehydration

Answer 130

c. Reduced GFR
d. Potential for fluid overload

The GFR refers to the initial amount of urine that the kidneys filter from the blood. In the healthy adult, the normal GFR ranges between 100 and 120 mL/min, most of which is reabsorbed in the kidney tubules. A GFR of 40 mL/min is drastically reduced, with the client experiencing fluid retention and risks for hypertension and pulmonary edema as a result of excess vascular fluid.

Question 131

4. A nurse assesses a client who is recovering from a nephrostomy. Which assessment findings should alert the nurse to urgently contact the health care provider? (Select all that apply.)
   a. Clear drainage
   b. Bloody drainage at site
   c. Client reports headache
   d. Foul-smelling drainage
   e. Urine draining from site

Answer 131

b. Bloody drainage at site
d. Foul-smelling drainage
e. Urine draining from site

After a nephrostomy, the nurse should assess the client for complications and urgently notify the provider if drainage decreases or stops, drainage is cloudy or foul-smelling, the nephrostomy sites leaks blood or urine, or the client has back pain. Clear drainage is normal. A headache would be an unrelated finding.

Question 132

5. A nurse teaches a client with polycystic kidney disease (PKD). Which statements should the nurse include in this client’s discharge teaching?
   (Select all that apply.)
   a. Take your blood pressure every morning.
   b. Weigh yourself at the same time each day.
   c. Adjust your diet to prevent diarrhea.
   d. Contact your provider if you have visual disturbances.
   e. Assess your urine for renal stones.

Answer 132

a. Take your blood pressure every morning.
b. Weigh yourself at the same time each day.
d. Contact your provider if you have visual disturbances.

A client who has PKD should measure and record his or her blood pressure and weight daily, limit salt intake, and adjust dietary selections to prevent constipation. The client should notify the provider if urine smells foul or has blood in it, as these are signs of a urinary tract infection or glomerular injury. The client should also notify the provider if visual disturbances are experienced, as this is a sign of a possible berry aneurysm, which is a complication of PKD. Diarrhea and renal stones are not manifestations or complications of PKD; therefore, teaching related to these concepts would be inappropriate.

Question 133

Chapter 72: Care of Patients with Male Reproductive Problems

Answer 133

LAST CHAPTER!

Question 134

1. The nurse is conducting a history on a male client to determine the severity of symptoms associated with prostate enlargement. Which finding is cause for prompt action by the nurse?
   a. Cloudy urine
   b. Urinary hesitancy
   c. Post-void dribbling
   d. Weak urinary stream

Answer 134

a. Cloudy urine

Cloudy urine could indicate infection due to possible urine retention and should be a priority action. Common symptoms of benign prostatic hyperplasia are urinary hesitancy, post-void dribbling, and a weak urinary stream due to the enlarged prostate causing bladder outlet obstruction.

Question 135

2. A client is diagnosed with benign prostatic hyperplasia and seems sad and irritable. After assessing the client’s behavior, which statement by the nurse would be the most appropriate?
   a. The urine incontinence should not prevent you from socializing.
   b. You seem depressed and should seek more pleasant things to do.
   c. It is common for men at your age to have changes in mood.
   d. Nocturia could cause interruption of your sleep and cause changes in mood.

Answer 135

d. Nocturia could cause interruption of your sleep and cause changes in mood.

Frequent visits to the bathroom during the night could cause sleep interruptions and affect the client’s mood and mental status. Incontinence could cause the client to feel embarrassment and cause him to limit his activities outside the home. The social isolation could lead to clinical depression and should be treated professionally. The nurse should not give advice before exploring the clients response to his change in behavior. The statement about age has no validity.

Question 136

3. A 55-year-old African-American client is having a visit with his health care provider. What test should the nurse discuss with the client as an option to screen for prostate cancer, even though screening is not routinely recommended?
   a. Complete blood count
   b. Culture and sensitivity
   c. Prostate-specific antigen
   d. Cystoscopy

Answer 136

c. Prostate-specific antigen

The prostate-specific antigen test should be discussed as an option for prostate cancer screening. A complete blood count and culture and sensitivity laboratory test will be ordered if infection is suspected. A cystoscopy would be performed to assess the effect of a bladder neck obstruction.

Question 137

4. The nurse is teaching a client with benign prostatic hyperplasia (BPH). What statement indicates a lack of understanding by the client?
   a. There should be no problem with a glass of wine with dinner each night.
   b. I am so glad that I weaned myself off of coffee about a year ago.
   c. I need to inform my allergist that I cannot take my normal decongestant.
   d. My normal routine of drinking a quart of water during exercise needs to change.

Answer 137

a. There should be no problem with a glass of wine with dinner each night.

This client did not associate wine with the avoidance of alcohol, and requires additional teaching. The nurse must teach a client with BPH to avoid alcohol, caffeine, and large quantities of fluid in a short amount of time to prevent overdistention of the bladder. Decongestants also need to be avoided to lower the chance for urinary retention.

Question 138

5. A client has returned from a transurethral resection of the prostate with a continuous bladder irrigation. Which action by the nurse is a priority if bright red urinary drainage and clots are noted 5 hours after the surgery?
   a. Review the hemoglobin and hematocrit as ordered.
   b. Take vital signs and notify the surgeon immediately.
   c. Release the traction on the three-way catheter.
   d. Remind the client not to pull on the catheter.

Answer 138

b. Take vital signs and notify the surgeon immediately.

Bright red urinary drainage with clots may indicate arterial bleeding. Vital signs should be taken and the surgeon notified. The traction on the three-way catheter should not be released since it places pressure at the surgical site to avoid bleeding. The nurses review of hemoglobin and hematocrit and reminding the client not to pull on the catheter are good choices, but not the priority at this time.

Question 139

6. A nurse and an unlicensed assistive personnel (UAP) are caring for a client with an open radical prostatectomy. Which comfort measure could the nurse delegate to the UAP?
   a. Administering an antispasmodic for bladder spasms
   b. Managing pain through patient-controlled analgesia
   c. Applying ice to a swollen scrotum and penis
   d. Helping the client transfer from the bed to the chair

Answer 139

d. Helping the client transfer from the bed to the chair

The UAP could aid the client in transferring from the bed to the chair and with ambulation. The nurse would be responsible for medication administration, assessment of swelling, and the application of ice if needed.

Question 140

12. A 70-year-old client returned from a transurethral resection of the prostate 8 hours ago with a continuous bladder irrigation. The nurse reviews his laboratory results as follows:
Sodium: 128 mEq/L
Hemoglobin: 14 g/dL
Hematocrit: 42%
RBC count: 4.5

What action by the nurse is the most appropriate?

a. Consider starting a blood transfusion.
b. Slow down the bladder irrigation if the urine is pink.
c. Report the findings to the surgeon immediately.
d. Take the vital signs every 15 minutes.

Answer 140

b. Slow down the bladder irrigation if the urine is pink.

The serum sodium is decreased due to large-volume bladder irrigation (normal is 136 to 145 mEq/L). By slowing the irrigation, there will be less fluid overload and sodium dilution. The hemoglobin and hematocrit values are a low normal, with a slight decrease in the red blood cell count. Therefore, a blood transfusion or frequent vital signs should not be necessary. Immediate report to the surgeon is not necessary.

Question 141

13. The nurse is teaching an uncircumcised 65-year-old client about self-management of a urinary catheter in preparation for discharge to his home. What statement indicates a lack of understanding by the client?
    a. I only have to wash the outside of the catheter once a week.
    b. I should take extra time to clean the catheter site by pushing the foreskin back.
    c. The drainage bag needs to be changed at least once a week and as needed.
    d. I should pour a solution of vinegar and water through the tubing and bag.

Answer 141

a. I only have to wash the outside of the catheter once a week.

The first few inches of the catheter must be washed daily starting at the penis and washing outward with soap and water. The other options are correct for self-management of a urinary catheter in the home setting.