Ignatavicius NCLEX Qs Flashcards

1
Q

How is hypoglycemia prevented in the healthy person who does not have diabetes even after fasting for 8
hours?

A. Metabolism is so slow when a person sleeps without eating for 8 hours that blood glucose does not
enter cells to be used for energy. As a result, hypoglycemia does not occur.
B. Fasting for 8 hours triggers conversion of proteins into glycogen (glycogenesis) so that
hyperglycemia develops rather than hypoglycemia.
C. Lipolysis (fat breakdown) in fat stores occurs, converting fatty acids into glucose to maintain
blood glucose levels.
D. The secretion of glucagon prevents hypoglycemia by promoting glucose release from liver storage
sites.

A

D
Rationale: Glucagon is a counterregulatory hormone secreted by pancreatic alpha cells when blood
glucose levels are low, as they would be during an 8-hour fast. The body’s metabolic rate does decrease
during sleep (which is not stated in this question) but not sufficiently to prevent hypoglycemia. Glucagon
works on the glycogen stored in the liver, breaking it down to glucose (glycogenolysis) molecules that are
then released into the blood to maintain blood glucose levels and prevent hypoglycemia. Although
proteins can be broken down and converted to glucose, they are not converted to glycogen. Fat
breakdown through lipolysis can provide fatty acids for fuel, but this is not glucose, and lipolysis does not
occur until all stored glycogen is used.

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2
Q

Which health problems are considered results of microvascular complications from long-term or poorly
controlled diabetes mellitus?
A. Obesity and hyperglycemia
B. Systolic hypertension and heart failure
C. Retinal hemorrhage and male erectile dysfunction
D. Diabetic ketoacidosis and hyperglycemic-hyperosmolar state

A

C
Rationale: Both retinal hemorrhage and male erectile dysfunction are caused by microvascular
complications. Structural problems in retinal vessels include areas of poor retinal circulation, edema, hard
fatty deposits in the eye, and retinal hemorrhages. Microvascular changes cause hypoxia and death of the
nerves needed for male erection. Systolic hypertension and heart failure are considered macrovascular
complications. Obesity and hyperglycemia are causes of microvascular complications and are not caused
by them. Diabetic ketoacidosis and hyperglycemic-hyperosmolar state are problems of hyperglycemia but
are not caused by microvascular changes.

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3
Q

Which statement made by a client who is learning about self-injection of insulin indicates to the nurse that
clarification is needed about injection site selection and rotation?
A. “The abdominal site is best because it is closest to the pancreas.”

B. “I can reach my thigh best, so I will use different areas of the same thigh.”
C. “By rotating sites within one area, my chance of having skin changes is less.”
D. “If I change my injection site from the thigh to an arm, the inulin absorption may be different.”

A

A
Rationale: The abdominal site has the fastest and most consistent rate of absorption because of the blood
vessels in the area, not because of its proximity to the pancreas.

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4
Q

While assessing the client who has had diabetes for 15 years, the nurse finds that he has decreased
sensory perception in both feet. What is the nurse’s best first action?
A. Document the finding as the only action.
B. Examine the feet for manifestations of injury.
C. Test the sensory perception of the client’s hands.
D. Tell the client that he now has peripheral neuropathy.

A

B
Rationale: When reduced peripheral sensory perception is present, the likelihood of injury is high. Any
open area or other problem on the foot of a person with diabetes is at great risk for infection and must be
managed carefully and quickly. Checking for sensory perception on the hands and other areas is important
but can come after a thorough foot examination.

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5
Q

During a clinic visit, you are reviewing the records of a 39-year-old patient who was diagnosed 5 years
ago with type 2 diabetes. You discover that, although he has always been extremely near-sighted, he has
not seen an ophthalmologist for 4 years. He has gained 12 lbs since his last visit a year ago. His laboratory
values show a fasting blood glucose level of 96 mg/dL, an A1C of 8.2%, a total cholesterol of 322 mg/dL,
and an LDL of 190 mg/dL. When you ask him about ophthalmology follow-up and point out his
laboratory values, he replies that because he is taking prescribed antidiabetic medication, he believes that
he won’t have all the diabetes complications that his father had. He further tells you that he did have his
eyes checked by an optometrist to make sure his prescription was accurate but that because he was
younger than 40 years old, he does not need intraocular pressure measurements.
1. How should you interpret his laboratory values in terms of his personal glucose regulation?
assist this patient in managing his diabetes?

A

How should you interpret his laboratory values in terms of his personal glucose regulation?
His fasting blood glucose level is acceptable and indicates that he has controlled his diabetes during
the past 24 hours. However, his hemoglobin A1C is high, indicating that his overall control for the
past several months is poor. It is possible that the current medication regimen is not sufficient to
manage his disease. The fact that his weight is increasing rather than decreasing and that his blood
lipid levels are quite high hint that his nutrition therapy is probably not being followed.

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6
Q

During a clinic visit, you are reviewing the records of a 39-year-old patient who was diagnosed 5 years
ago with type 2 diabetes. You discover that, although he has always been extremely near-sighted, he has
not seen an ophthalmologist for 4 years. He has gained 12 lbs since his last visit a year ago. His laboratory
values show a fasting blood glucose level of 96 mg/dL, an A1C of 8.2%, a total cholesterol of 322 mg/dL,
and an LDL of 190 mg/dL. When you ask him about ophthalmology follow-up and point out his
laboratory values, he replies that because he is taking prescribed antidiabetic medication, he believes that
he won’t have all the diabetes complications that his father had. He further tells you that he did have his
eyes checked by an optometrist to make sure his prescription was accurate but that because he was
younger than 40 years old, he does not need intraocular pressure measurements.
2. Should you address his weight gain? Why or why not?

A

Should you address his weight gain? Why or why not?
Yes, you should address his weight. A major pathophysiological problem with type 2 diabetes is

insulin resistance. Increasing weight correlates to greater insulin resistance. Even modest weight loss
can improve the sensitivity of insulin receptors to insulin. The excess weight is contributing even
more to his risk for cardiovascular events, as evidenced by the high blood lipid levels.

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7
Q

During a clinic visit, you are reviewing the records of a 39-year-old patient who was diagnosed 5 years
ago with type 2 diabetes. You discover that, although he has always been extremely near-sighted, he has
not seen an ophthalmologist for 4 years. He has gained 12 lbs since his last visit a year ago. His laboratory
values show a fasting blood glucose level of 96 mg/dL, an A1C of 8.2%, a total cholesterol of 322 mg/dL,
and an LDL of 190 mg/dL. When you ask him about ophthalmology follow-up and point out his
laboratory values, he replies that because he is taking prescribed antidiabetic medication, he believes that
he won’t have all the diabetes complications that his father had. He further tells you that he did have his
eyes checked by an optometrist to make sure his prescription was accurate but that because he was
younger than 40 years old, he does not need intraocular pressure measurements.

  1. Is he correct in thinking that an ophthalmologist visit is not necessary at this time? Explain your
    response.
A

Is he correct in thinking that an ophthalmologist visit is not necessary at this time? Explain your
response.
Even if he did not have a vision problem, his risk for ophthalmic complications leading to blindness is
high. Just having diabetes is a reason to been seen by an ophthalmologist rather than an optometrist
(who is not a medical doctor). Depending on the control of his disease (which right now is not very
controlled), coupled with long-standing vision problems, he should be seen yearly by an
ophthalmologist. The ophthalmologist can determine whether a less frequent evaluation cycle would
be appropriate.

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8
Q

During a clinic visit, you are reviewing the records of a 39-year-old patient who was diagnosed 5 years
ago with type 2 diabetes. You discover that, although he has always been extremely near-sighted, he has
not seen an ophthalmologist for 4 years. He has gained 12 lbs since his last visit a year ago. His laboratory
values show a fasting blood glucose level of 96 mg/dL, an A1C of 8.2%, a total cholesterol of 322 mg/dL,
and an LDL of 190 mg/dL. When you ask him about ophthalmology follow-up and point out his
laboratory values, he replies that because he is taking prescribed antidiabetic medication, he believes that
he won’t have all the diabetes complications that his father had. He further tells you that he did have his
eyes checked by an optometrist to make sure his prescription was accurate but that because he was
younger than 40 years old, he does not need intraocular pressure measurements.

  1. Is he correct in believing that taking antidiabetic medication will prevent complications of
    diabetes? Explain your response.
A

Is he correct in believing that taking antidiabetic medication will prevent complications of diabetes?
Explain your response.
He is not correct in his thinking. Diabetes is a complex disorder and can only be controlled with a
combination of antidiabetic medications and life-style changes that include nutrition therapy,
maintenance of a healthy weight, blood pressure control, blood lipid control, and physical activity.
The drugs are only part of the management plan. The fact that he was diagnosed at an earlier age and
is taking medications is helpful, but without proper management, the complications of diabetes will
not even be delayed let alone prevented.

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9
Q

During a clinic visit, you are reviewing the records of a 39-year-old patient who was diagnosed 5 years
ago with type 2 diabetes. You discover that, although he has always been extremely near-sighted, he has
not seen an ophthalmologist for 4 years. He has gained 12 lbs since his last visit a year ago. His laboratory
values show a fasting blood glucose level of 96 mg/dL, an A1C of 8.2%, a total cholesterol of 322 mg/dL,
and an LDL of 190 mg/dL. When you ask him about ophthalmology follow-up and point out his
laboratory values, he replies that because he is taking prescribed antidiabetic medication, he believes that
he won’t have all the diabetes complications that his father had. He further tells you that he did have his
eyes checked by an optometrist to make sure his prescription was accurate but that because he was
younger than 40 years old, he does not need intraocular pressure measurements.

  1. How do you propose to assist this patient in managing his diabetes?
A

How do you propose to assist this patient in managing his diabetes?
The patient’s comments and the laboratory data indicate that he does not understand the disease, its
consequences, management techniques, and his role in the management plan. His issues are going to
require more than your intervention, although you can get this started. Patient-centered evaluation and
management with the entire diabetes management team is needed as soon as possible. He will need
further testing to assess for early-stage complications and possible changes to his medication regimen.
You should start by asking what he knows about the disease and correct any misunderstandings.
Bringing in a diabetes educator, the health care provider and registered dietitian is really needed now.
If classes are available, he should be strongly encouraged to start them. If he has a partner, try to
include her or him in this process. Essentially, this patient requires that the team treat him as if he had
just been newly diagnosed with diabetes.

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10
Q

The patient is a 60 year-old-woman who is 1 day postoperative after a total knee replacement. She has
type 2 diabetes and just recently was switched from oral antidiabetic drugs to an insulin regimen. She let
her nurse know that her on-demand lunch has been ordered. The nurse tests her blood and gives her the
prescribed short-acting insulin dose. An hour later, the physical therapist finds her pale, confused, and
clammy. Her lunch tray is on her table and appears totally untouched.
1. Is her condition consistent with hyperglycemia or hypoglycemia? Explain your choice.

A

Is her condition consistent with hyperglycemia or hypoglycemia? Explain your choice.
Her condition is consistent with hypoglycemia, especially because she received insulin about an hour
ago. Manifestations of hypoglycemia include weakness; difficulty thinking; confusion; sweating; and
cool, pale skin, and manifestations of hyperglycemia include warm, moist skin and possible fruity
breath odor. Hyperglycemia does not change level of consciousness until it is severe.

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11
Q

The patient is a 60 year-old-woman who is 1 day postoperative after a total knee replacement. She has
type 2 diabetes and just recently was switched from oral antidiabetic drugs to an insulin regimen. She let
her nurse know that her on-demand lunch has been ordered. The nurse tests her blood and gives her the
prescribed short-acting insulin dose. An hour later, the physical therapist finds her pale, confused, and
clammy. Her lunch tray is on her table and appears totally untouched.
2. What is your first action? Provide a rationale.

A

What is your first action? Provide a rationale.
Check her blood glucose level immediately because the methods to increase her blood glucose level
are dependent on how low the current level is.

a. As an alternative, if there is an easily digestible carbohydrate on her tray and she is able to
swallow, you could give that to her immediately and then obtain a blood glucose
measurement. However, this is less precise.

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12
Q

The patient is a 60 year-old-woman who is 1 day postoperative after a total knee replacement. She has
type 2 diabetes and just recently was switched from oral antidiabetic drugs to an insulin regimen. She let
her nurse know that her on-demand lunch has been ordered. The nurse tests her blood and gives her the
prescribed short-acting insulin dose. An hour later, the physical therapist finds her pale, confused, and
clammy. Her lunch tray is on her table and appears totally untouched.
3. What is the most likely cause leading to this problem?

A

What is the most likely cause leading to this problem?
Clearly, there was a delay in eating after receiving the insulin. The tray may have been delayed longer
than expected from food service, or perhaps she decided she was not hungry when it first arrived. She
could have been interrupted (possible phone call or visitor) before she had a chance to eat it. In
addition, it is possible because she has only recently been started on insulin that she did not
understand the necessity of eating soon after receiving insulin.

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13
Q

The patient is a 60 year-old-woman who is 1 day postoperative after a total knee replacement. She has
type 2 diabetes and just recently was switched from oral antidiabetic drugs to an insulin regimen. She let
her nurse know that her on-demand lunch has been ordered. The nurse tests her blood and gives her the
prescribed short-acting insulin dose. An hour later, the physical therapist finds her pale, confused, and
clammy. Her lunch tray is on her table and appears totally untouched.
4. What could be done on this nursing care unit to prevent such an incident from happening again?

A

What could be done on this nursing care unit to prevent such an incident from happening again?
The patient should receive more education about the relationship between insulin and eating. The unit
needs to establish guidelines or policies about premeal insulin administration. Perhaps it should not be
administered until the tray is actually in the patient’s possession and the patient is ready to eat it. Also,
whenever short-acting insulin is given, the nurse giving it should evaluate the patient within 20
minutes.

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14
Q
A client previously diagnosed with liver cirrhosis visits the medical clinic. What assessment findings does
the nurse expect in this client? Select all that apply.
A. Ecchymosis
B. Soft abdomen
C. Moist, clammy skin
D. Jaundice
E. Ankle edema
F. Fever
A

A, D, E
Rationale: Clients with advanced cirrhosis often have symptoms such as gastrointestinal (GI) bleeding,
jaundice, ascites, and spontaneous bruising. They may also have dry skin, rashes, purpuric lesions (e.g.,
petechiae), warm and bright red palms of the hands, vascular lesions (spider angiomas), and peripheral
dependent edema of the extremities and sacrum.

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15
Q

The nurse is providing teaching for a client scheduled for a paracentesis. Which statement by the client
indicates the teaching has been successful?
A. “I must not use the bathroom prior to the procedure.”
B. “I will lie on my stomach while the procedure is performed.”
C. “I will not be allowed to eat or drink anything the night before surgery.”
D. “The physician will likely remove 2 to 3 liters of fluid from my abdomen.”

A

D
Rationale: The client should void before the procedure to prevent injury to the bladder. The client will lie
in bed with the head of the bed elevated during the procedure.

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16
Q

Which intervention will the nurse include in the plan of care for a client with severe liver disease?
A. Encourage the client to eat a low-protein, high-carbohydrate diet.
B. Administer Kayexalate enemas.
C. Encourage the client to eat a high-protein, low-carbohydrate diet.
D. Participate in frequent, vigorous physical activities.

A

A
Rationale: The client with severe liver disease should eat a diet high in carbohydrates and calories with
moderate amounts of fat and protein. Kayexalate enemas and frequent, vigorous physical activities should
be avoided.

17
Q

What effect on circulating levels of sodium and glucose does the nurse expect in a client who has been
taking an oral cortisol preparation for 2 years because of a respiratory problem?
A. Decreased sodium; decreased glucose
B. Decreased sodium; increased glucose
C. Increased sodium; decreased glucose
D. Increased sodium; increased glucose

A

D
Rationale: Any of the glucocorticoids have some mineralocorticoid activity and increase the reabsorption
of sodium from the kidney tubules, thus increasing the serum sodium level. Cortisol also increases liver
production of glucose (gluconeogenesis) and inhibits peripheral glucose uptake by the cells. Both of these
actions increase blood glucose levels.

18
Q

Which precaution or action is most important for the nurse to teach the client who is to collect a 24-hour
urine specimen for endocrine testing?
A. Eat a normal diet during the collection period.
B. Wear gloves when you urinate to prevent contamination of the specimen.
C. Urinate at the end of 24 hours and add that sample to the collection container.
D. Avoid walking, running, dancing, or any vigorous exercise during the collection period.

A

C
Rationale: When a 24-hour urine specimen is started, the specimen should reflect all the urine produced
during the specified time. The very first voiding is discarded because the urine has spent some time in the
bladder and will not reflect what is happening during the actual 24 hours of the collection. The time of
this discard is the beginning of the 24-hour collection period. The test requires that all urine voided after
the start time be collected, including the specimen collected by emptying the bladder at end of the 24
hours, which marks the end of the test.

19
Q

For which client does the nurse question the prescription of androgen replacement therapy?
A. 35-year-old man who has had a vasectomy
B. 48-year old man who takes prednisone for severe asthma
C. 62-year-old man who has a history of prostate cancer
D. 70-year-old man who has hypertension and type 2 diabetes

A

C
Rationale: Prostate cancer tends to increase its growth rate in the presence of any type of androgen. Thus,
the man who has a history of prostate cancer should avoid exogenous androgen because it could enhance
the growth if the previously treated cancer returns. None of the other conditions are contraindicated for
androgen replacement therapy.

20
Q

Which urine properties indicate to the nurse that the client with syndrome of inappropriate (SIADH)
antidiuretic hormone is responding to interventions?
A. Urine output volume increased; urine specific gravity increased
B. Urine output volume increased; urine specific gravity decreased
C. Urine output volume decreased; urine specific gravity increased
D. Urine output volume decreased; urine specific gravity decreased

A

B
Rationale: SIADH involves excessive secretion of vasopressin (ADH) when it is not needed. Water is
reabsorbed, causing an increase in blood volume and a decrease in urine volume. Blood concentration is
diluted, and urine concentration, as measured by specific gravity, is highly increased. When interventions
to counter act SIADH are effective, the person slows water reabsorption so that urine output volume
increases at the same time that urine concentration decreases, seen as a decreased urine specific gravity.

21
Q

The client who is about to have a unilateral adrenalectomy for an adenoma that is causing
hypercortisolism asks the nurse if she will have to continue the severe sodium restriction after surgery.
What is the nurse’s best response?
A. “No, once the tumor has been removed and your cortisol levels have normalized, you will not
retain excess sodium anymore.”
B. “No, after surgery you will have to take oral cortisol, which can easily be controlled so that your
sodium levels do not rise.”
C. Yes, the fact that you are retaining sodium and have high blood pressure is related to your age and
lifestyle, not the tumor.”
D. “Yes, sodium is very bad for people and everyone needs to eliminate sodium completely from
their diets for the rest of their lives.”

A

A

Rationale: A tumor secreting excessive amounts of cortisol is this patient’s reason for needing to severely
restrict her sodium. After the tumor is removed, she will not have hypercortisolism but may have to take
oral cortisol until the remaining adrenal gland begins to secrete sufficient cortisol. She will no longer
experience severe sodium retention. Although people in North America tend to have high-sodium diets
and many could stand to reduce their sodium intake, sodium is an essential element and cannot be
eliminated from the diet.

22
Q
Which manifestations are most often seen in general hyperthyroidism? Select all that apply.
A. Increased appetite
B. Cold intolerance
C. Constipation
D. Increased sweating
E. Insomnia
F. Palpitations
G. Tremors
H. Weight gain
A

A, D, E, F, G
Rationale: The person with any type of hyperthyroidism has increased metabolism, which causes an
increased appetite, increased sweating, increased nervous system stimulation (tremors and insomnia), and
increased cardiovascular responses (palpitations). In most people with hyperthyroidism, all other systems
are also stimulated, causing increased bowel movements (not constipation) and an elevated body
temperature (not cold intolerance). Even though appetite is increased, most people lose weight.

23
Q

For which assessment finding in a client who has severe hyperthyroidism does the nurse notify the Rapid
Response Team?
A. An increase in premature ventricular heart contractions from 4 per minute to 5 per minute
B. An increase in or widening of pulse pressure from 40 mm Hg to 46 mm Hg
C. An increase in temperature from 99.5° F (37.5° C) to 101.3° F (38.5° C)
D. An increase of 20 mL of urine output per hour

A

C
Rationale: Although all changes listed are concerning, the one most associated with impending thyroid
storm (thyroid crisis) is the increase in body temperature. This client requires immediate attention.

24
Q

When taking the blood pressure of a client receiving treatment for hyperparathyroidism, the nurse
observes the client’s hand to undergo flexion contractions. What is the nurse’s interpretation of this
observation?
A. Hyperphosphatemia
B. Hypophosphatemia
C. Hypercalcemia
D. Hypocalcemia

A

D
Rationale: 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 occurring during blood pressure measurement are indicative of hypocalcemia and referred to
as a positive Trousseau’s sign.

25
Q

A client in the community health clinic is prescribed trimethoprim/sulfamethoxazole for cystitis. She
reports that she developed hives to “something called Septra.” What is the nurse’s best action?
A. Reassure the client that Septra is not trimethoprim/sulfamethoxazole.
B. Highlight this important information in the client’s medical record.
C. Place an allergy alert band on the client’s wrist.
D. Notify the prescriber immediately.

A

Septra is a brand name for TMP-SMX, a sulfa-based antibiotic with multiple brand names. It is
inappropriate to band a wrist in a community health clinic. This information may need to be added to the
client’s medical record, but simply highlighting the information will not prevent an avoidable adverse
drug event. The provider needs the allergy information in order to substitute another effective antibiotic.

26
Q

For which hospitalized client does the nurse recommend the ongoing use of a urinary catheter?
A. 36-year-old woman who is blind receiving diuretics
B. 46-year-old man who has paraplegia and is admitted for asthma management
C. 56-year-old woman who is admitted with a vaginal-rectal fistula and diabetes
D. 66-year-old man who has severe osteoarthritis and high risk for falling

A

C
Rationale: This client has a wound that can be irritated by urine and whose urinary tract could become
infected by the draining fistula (her diabetes increases her overall risk for infection). All of these other
clients could be managed with frequent toileting. The men could also be managed with external urine
collection devices.

27
Q

The client passes a urinary stone that laboratory analysis indicates is composed of calcium oxalate. Based
on this analysis, which instruction does the nurse specifically include for dietary prevention of the
problem?
A. “Increase your intake of meat, fish, and cranberry juice.”
B. “Avoid citrus fruits and citrus juices such as oranges.”
C. “Avoid dark green leafy vegetables such as spinach.”
D. “Decrease your intake of dairy products, especially milk.”

A

C
Rationale: Calcium oxalate stones form more easily in the presence of oxalate. Sources of oxalate include
spinach, black tea, and rhubarb. Avoiding these sources of oxalate may reduce the number of stones
formed. Citrus intake is not restricted in this type of stone and is often suggested to be increased. Dietary
intake of calcium does not appear to affect calcium-based stone formation, although the client should
avoid calcium mineral supplements. Moderation of meat reduces stone formation in general.

28
Q

A 65-year old client is seeing his primary care provider for an annual examination. Which assessment
finding alerts the nurse to an increased risk for bladder cancer?
A. Smoking
B. Urine with a high specific gravity
C. Recurrent urinary tract infections
D. History of cancer in another organ or tissue

A

A
Rationale: Many compounds in tobacco enter the bloodstream and affect other organs, such as the
bladder. Concentrated urine is associated with kidney stones and UTIs. The urinary bladder is not a
common site for metastases.

29
Q

The client arrives to the primary care clinic with a problem of new abdominal pain and blood in her urine.
She is afebrile. Which information is most important for the nurse to obtain from this client’s history?
A. Kidney cancer in the client’s family
B. Injury or trauma to the abdomen or pelvis
C. Treatment for a urinary tract infection in the past 12 months
D. Recent exposure to heavy metals, drugs, or other nephrotoxins

A

B
Rationale: Bladder trauma or injury should be considered in the patient with abdominal pain. Lack of
fever reduces suspicion for infection; pain is not usually associated with kidney cancer or acute and
chronic kidney injury from nephrotoxins

30
Q
The client’s urinalysis shows all of the following abnormal results. Which result does the nurse report to
the health care provider immediately?
A. pH 7.8
B. Protein 31 mg
C. Sodium 15 mEq/L
D. Leukoesterase and nitrate positive
A

D
Rationale: Although the alkaline pH is abnormal, it may be the results of diet or other benign factors; the
slight increase in protein is concerning but not urgent and may be explained by diet, strenuous activity, or
other benign causes, similar to the slightly elevated sodium, which could be from salty food ingestion.
However, the most common cause of positive leukoesterase result is a UTI, and this test is further
confirmed with a positive nitrate result.

31
Q

Which assessments are most important for the nurse to perform when monitoring a client who returns to
the medical-surgical unit after a dye-enhanced CT scan?
A. Body temperature and urine odor
B. Kidney tenderness and flank pain
C. Urine volume and color
D. Specific gravity and pH

A

C
Rationale: To prevent dye-induced nephrotoxicity, the nurse should evaluate the urine and ensure a large,
dilute output for several hours after the test. Generally, the amount of contrast does not cause dehydration;
the concern is that the high osmolar content of some dyes has a direct nephrotoxic affect. Kidney
tenderness and flank pain may indicate bleeding, a complication from a kidney biopsy. Body temperature
and urine odor may indicate a UTI after manipulation of the urinary tract system and manipulation (e.g.,
placement of a urinary catheter or instilling of fluid into the bladder) does not occur with a CT scan.

32
Q

Which statement made by the client newly diagnosed with polycystic kidney disease (PKD) indicates to
the nurse that additional teaching for self-management is needed?
A. “I will need to increase my daily water intake.”
B. “I will restrict my sodium to less than 2 mg daily.”
C. “Now I will need to take a blood pressure drug daily.”
D. “If I become sexually active or plan to have a family, I will seek genetic counseling.”

A

B
Rationale: Patients with PKD waste sodium rather than retaining it. They need an increased sodium and
water intake. Aggressive control of hypertension is needed to preserve kidney function. Genetic
counseling is advised before having children because PKD is inherited.

33
Q

When providing care to a client who has undergone a nephrostomy for hydronephrosis, which observation
alerts the nurse to a possible complication?
A. Urine output of 15 mL/hr
B. Tenderness at the surgical site
C. Blood urea nitrogen (BUN) of 23 mg/dL
D. Pink-tinged urine draining from the nephrostomy

A

A
Rationale: Urine output after a nephrostomy should be at least 25 to 40 mL/hr. Tenderness is expected at
a new incisional site; the slight elevation of BUN alone is not alarming or indicative of a complication
specific to nephrostomy. Pink-tinged urine indicating hematuria is common after instrumentation, but
frank blood or increased bleeding over time is not expected.

34
Q

When assessing a client with diabetic nephropathy, which question about self-management should the
nurse ask to determine whether the client is currently following best practices to slow progression of this
condition?
A. “Have you increased your protein intake to promote healing of the damaged nephrons?”
B. “Do you avoid contact sports to reduce the risk for causing trauma to your kidneys?”
C. “How do you manage your diet to keep your blood glucose levels in the target range?”
D. “Have you increased your fluid intake based on urine output?”

A

C
Rationale: All strategies to avoid prolonged or frequent hyperglycemia can slow progression of diabetic
complications, and the open-ended question is nonjudgmental. Protein intake is likely to be advised to be
decreased in response to kidney damage regardless of cause. Avoiding renal trauma is a good idea but not
linked to best practices in diabetic nephropathy care. Although increasing fluid intake based on urine
output may be a good idea during periods of strenuous activity or other dehydrating conditions, it is not

linked to best practices for this condition.