MS Exam 1 Flashcards
The nurse is caring for a patient with a massive burn injury and possible hypovolemia. Which assessment data will be of most concern to the nurse?
a. Urine output is 30 mL/hr.
b. Blood pressure is 90/40 mm Hg.
c. Oral fluid intake is 100 mL for the past 8 hours.
d. There is prolonged skin tenting over the sternum.
ANS: B
The blood pressure indicates that the patient may be developing hypovolemic shock as a result of intravascular fluid loss because of the burn injury. This finding will require immediate intervention to prevent the complications associated with systemic hypoperfusion. The poor oral intake, decreased urine output, and skin tenting all indicate the need for increasing the patient’s fluid intake but not as urgently as the hypotension.
A patient who has a small cell carcinoma of the lung develops syndrome of inappropriate antidiuretic hormone (SIADH). The nurse should notify the health care provider about which assessment finding?
a. Serum hematocrit of 42%
b. Serum sodium level of 120 mg/dL
c. Reported weight gain of 2.2 lb (1 kg)
d. Urinary output of 280 mL during past 8 hours
ANS: B
Hyponatremia is the most important finding to report. SIADH causes water retention and a decrease in serum sodium level. Hyponatremia can cause confusion and other central nervous system effects. A critically low value likely needs to be treated. At least 30 mL/hr of urine output indicates adequate kidney function. The hematocrit level is normal. Weight gain is expected with SIADH because of water retention.
A patient with multiple draining wounds is admitted for hypovolemia. Which assessment would be the most accurate way for the nurse to evaluate fluid balance?
a. Skin turgor c. Urine output
b. Daily weight d. Edema presence
ANS: B
Daily weight is the most easily obtained and accurate means of assessing volume status. Skin turgor varies considerably with age. Considerable excess fluid volume may be present before fluid moves into the interstitial space and causes edema. Urine outputs do not take account of fluid intake or of fluid loss through insensible loss, sweating, or loss from the gastrointestinal tract or wounds.
The home health nurse cares for an alert and oriented older adult patient with a history of dehydration. Which instructions should the nurse give this patient related to fluid intake?
a. “Drink more fluids in the late evening.”
b. “Increase fluids if your mouth feels dry.”
c. “More fluids are needed if you feel thirsty.”
d. “If you feel confused, you need more to drink.”
ANS: B
An alert older patient will be able to self-assess for signs of oral dryness such as thick oral secretions or dry-appearing mucosa. The thirst mechanism decreases with age and is not an accurate indicator of volume depletion. Many older patients prefer to restrict fluids slightly in the evening to improve sleep quality. The patient will not be likely to notice and act appropriately when changes in level of consciousness occur.
A patient who is taking a potassium-wasting diuretic for treatment of hypertension complains of generalized weakness. Which action is appropriate for the nurse to take?
a. Assess for facial muscle spasms.
b. Ask the patient about loose stools.
c. Recommend the patient avoid drinking orange juice with meals.
d. Suggest that the health care provider order a basic metabolic panel.
ANS: D
Generalized weakness is a manifestation of hypokalemia. After the health care provider orders the metabolic panel, the nurse should check the potassium level. Facial muscle spasms might occur with hypocalcemia. Orange juice is high in potassium and would be advisable to drink if the patient is hypokalemic. Loose stools are associated with hyperkalemia.
Spironolactone (Aldactone), an aldosterone antagonist, is prescribed for a patient. Which statement by the patient indicates that the teaching about this medication has been effective?
a. “I will try to drink at least 8 glasses of water every day.”
b. “I will use a salt substitute to decrease my sodium intake.”
c. “I will increase my intake of potassium-containing foods.”
d. “I will drink apple juice instead of orange juice for breakfast.”
ANS: D
Because spironolactone is a potassium-sparing diuretic, patients should be taught to choose low-potassium foods (e.g., apple juice) rather than foods that have higher levels of potassium (e.g., citrus fruits). Because the patient is using spironolactone as a diuretic, the nurse would not encourage the patient to increase fluid intake. Teach patients to avoid salt substitutes, which are high in potassium.
A patient with new-onset confusion and hyponatremia is being admitted. When making room assignments, the charge nurse should take which action?
a. Assign the patient to a semi-private room.
b. Assign the patient to a room near the nurse’s station.
c. Place the patient in a room nearest to the water fountain.
d. Place the patient on telemetry to monitor for peaked T waves..
ANS: B
The patient should be placed near the nurse’s station if confused for the staff to closely monitor the patient. To help improve serum sodium levels, water intake is restricted. Therefore a confused patient should not be placed near a water fountain. Peaked T waves are a sign of hyperkalemia, not hyponatremia. A confused patient could be distracting and disruptive for another patient in a semiprivate room.
IV potassium chloride (KCl) 60 mEq is prescribed for treatment of a patient with severe hypokalemia. Which action should the nurse take?
a. Administer the KCl as a rapid IV bolus.
b. Infuse the KCl at a rate of 10 mEq/hour.
c. Only give the KCl through a central venous line.
d. Discontinue cardiac monitoring during the infusion.
ANS: B
IV KCl is administered at a maximal rate of 10 mEq/hr. Rapid IV infusion of KCl can cause cardiac arrest. KCl can cause inflammation of peripheral veins, but it can be administered by this route. Cardiac monitoring should be continued while patient is receiving potassium because of the risk for dysrhythmias.
A postoperative patient who had surgery for a perforated gastric ulcer has been receiving nasogastric suction for 3 days. The patient now has a serum sodium level of 127 mEq/L (127 mmol/L). Which prescribed therapy should the nurse question?
a. Infuse 5% dextrose in water at 125 mL/hr.
b. Administer 3% saline at 50 mL/hr for a total of 200 mL.
c. Administer IV morphine sulfate 4 mg every 2 hours PRN.
d. Give IV metoclopramide (Reglan) 10 mg every 6 hours PRN for nausea.
ANS: A
Because the patient’s gastric suction has been depleting electrolytes, the IV solution should include electrolyte replacement. Solutions such as lactated Ringer’s solution would usually be ordered for this patient. The other orders are appropriate for a postoperative patient with gastric suction.
A patient who was involved in a motor vehicle crash has had a tracheostomy placed to allow for continued mechanical ventilation. How should the nurse interpret the following arterial blood gas results: pH 7.48, PaO2 85 mm Hg, PaCO2 32 mm Hg, and HCO3 25 mEq/L?
a. Metabolic acidosis c. Respiratory acidosis
b. Metabolic alkalosis d. Respiratory alkalosis
ANS: D
The pH indicates that the patient has alkalosis and the low PaCO2 indicates a respiratory cause. The other responses are incorrect based on the pH and the normal HCO3.
The nurse notes that a patient who was admitted with diabetic ketoacidosis has rapid, deep respirations. Which action should the nurse take?
a. Give the prescribed PRN lorazepam (Ativan).
b. Encourage the patient to take deep slow breaths.
c. Start the prescribed PRN oxygen at 2 to 4 L/min.
d. Administer the prescribed normal saline bolus and insulin.
ANS: D
The rapid, deep (Kussmaul) respirations indicate a metabolic acidosis and the need for correction of the acidosis with a saline bolus to prevent hypovolemia followed by insulin administration to allow glucose to reenter the cells. Oxygen therapy is not indicated because there is no indication that the increased respiratory rate is related to hypoxemia. The respiratory pattern is compensatory, and the patient will not be able to slow the respiratory rate. Lorazepam administration will slow the respiratory rate and increase the level of acidosis.
An older adult patient who is malnourished presents to the emergency department with a serum protein level of 5.2 g/dL. The nurse would expect which clinical manifestation?
a. Pallor c. Confusion
b. Edema d. Restlessness
ANS: B
The normal range for total protein is 6.4 to 8.3 g/dL. Low serum protein levels cause a decrease in plasma oncotic pressure and allow fluid to remain in interstitial tissues, causing edema. Confusion, restlessness, and pallor are not associated with low serum protein levels.
A patient receives 3% NaCl solution for correction of hyponatremia. Which assessment is most important for the nurse to monitor for while the patient is receiving this infusion?
a. Lung sounds c. Peripheral pulses
b. Urinary output d. Peripheral edema
ANS: A
Hypertonic solutions cause water retention, so the patient should be monitored for symptoms of fluid excess. Crackles in the lungs may indicate the onset of pulmonary edema and are a serious manifestation of fluid excess. Peripheral pulses, peripheral edema, or changes in urine output are also important to monitor when administering hypertonic solutions, but they do not indicate acute respiratory or cardiac decompensation.
The long-term care nurse is evaluating the effectiveness of protein supplements for an older resident who has a low serum total protein level. Which assessment finding indicates that the patient’s condition has improved?
a. Hematocrit 28% c. Decreased peripheral edema
b. Absence of skin tenting d. Blood pressure 110/72 mm Hg
ANS: C
Edema is caused by low oncotic pressure in individuals with low serum protein levels. The decrease in edema indicates an improvement in the patient’s protein status. Good skin turgor is an indicator of fluid balance, not protein status. A low hematocrit could be caused by poor protein intake. Blood pressure does not provide a useful clinical tool for monitoring protein status.
A patient who is lethargic and exhibits deep, rapid respirations has the following arterial blood gas (ABG) results: pH 7.32, PaO2 88 mm Hg, PaCO2 37 mm Hg, and HCO3 16 mEq/L. How should the nurse interpret these results?
a. Metabolic acidosis c. Respiratory acidosis
b. Metabolic alkalosis d. Respiratory alkalosis
ANS: A
The pH and HCO3 indicate that the patient has a metabolic acidosis. The ABGs are inconsistent with the other responses.
A patient who has been receiving diuretic therapy is admitted to the emergency department with a serum potassium level of 3.0 mEq/L. The nurse should alert the health care provider immediately that the patient is on which medication?
a. Digoxin (Lanoxin) 0.25 mg/day
b. Metoprolol (Lopressor) 12.5 mg/day
c. Ibuprofen (Motrin) 400 mg every 6 hours
d. Lantus insulin 24 U subcutaneously every evening
ANS: A
Hypokalemia increases the risk for digoxin toxicity, which can cause serious dysrhythmias. The nurse will also need to do more assessment regarding the other medications, but they are not of as much concern with the potassium level.
The nurse is caring for a patient who has a calcium level of 12.1 mg/dL. Which nursing action should the nurse include on the care plan?
a. Maintain the patient on bed rest.
b. Auscultate lung sounds every 4 hours.
c. Monitor for Trousseau’s and Chvostek’s signs.
d. Encourage fluid intake up to 4000 mL every day.
ANS: D
To decrease the risk for renal calculi, the patient should have a fluid intake of 3000 to 4000 mL daily. Ambulation helps decrease the loss of calcium from bone and is encouraged in patients with hypercalcemia. Trousseau’s and Chvostek’s signs are monitored when there is a possibility of hypocalcemia. There is no indication that the patient needs frequent assessment of lung sounds, although these would be assessed every shift.
When caring for a patient with renal failure on a low phosphate diet, the nurse will inform unlicensed assistive personnel (UAP) to remove which food from the patient’s food tray?
a. Skim milk c. Mixed green salad
b. Grape juice d. Fried chicken breast
ANS: A
Foods high in phosphate include milk and other dairy products, so these are restricted on low-phosphate diets. Green, leafy vegetables; high-fat foods; and fruits and juices are not high in phosphate and are not restricted.
A patient has a magnesium level of 1.3 mg/dL. Which assessment would help the nurse identify a likely cause of this value?
a. Daily alcohol intake
b. Dietary protein intake
c. Multivitamin/mineral use
d. Over-the-counter (OTC) laxative use
ANS: A
Hypomagnesemia is associated with alcoholism. Protein intake would not have a significant effect on magnesium level. OTC laxatives (such as milk of magnesia) and use of multivitamin/mineral supplements tend to increase magnesium levels.
A patient has a parenteral nutrition infusion of 25% dextrose. A student nurse asks the nurse why a peripherally inserted central catheter was inserted. Which response by the nurse is accurate?
a. “The prescribed infusion can be given more rapidly when the patient has a central line.”
b. “The hypertonic solution will be more rapidly diluted when given through a central line.”
c. “There is a decreased risk for infection when 25% dextrose is infused through a central line.”
d. “The required blood glucose monitoring is based on samples obtained from a central line.”
ANS: B
The 25% dextrose solution is hypertonic. Shrinkage of red blood cells can occur when solutions with dextrose concentrations greater than 10% are administered IV. Blood glucose testing is not more accurate when samples are obtained from a central line. The infection risk is higher with a central catheter than with peripheral IV lines. Hypertonic or concentrated IV solutions are not given rapidly.
The nurse is caring for a patient who has a central venous access device (CVAD). Which action by the nurse is appropriate?
a. Avoid using friction when cleaning around the CVAD insertion site.
b. Use the push-pause method to flush the CVAD after giving medications.
c. Obtain an order from the health care provider to change CVAD dressing.
d. Position the patient’s face toward the CVAD during injection cap changes.
ANS: B
The push-pause enhances the removal of debris from the CVAD lumen and decreases the risk for clotting. To decrease infection risk, friction should be used when cleaning the CVAD insertion site. The dressing should be changed whenever it becomes damp, loose, or visibly soiled. A provider’s order is not necessary. The patient should turn away from the CVAD during cap changes.
An older patient receiving iso-osmolar continuous tube feedings develops restlessness, agitation, and weakness. Which laboratory result should the nurse report to the health care provider immediately?
a. K+ 3.4 mEq/L (3.4 mmol/L) c. Na+ 154 mEq/L (154 mmol/L)
b. Ca+2 7.8 mg/dL (1.95 mmol/L) d. PO4-3 4.8 mg/dL (1.55 mmol/L)
ANS: C
The elevated serum sodium level is consistent with the patient’s neurologic symptoms and indicates a need for immediate action to prevent further serious complications such as seizures. The potassium, phosphate, and calcium levels vary slightly from normal but do not require immediate action by the nurse.
The nurse assesses a patient who has been hospitalized for 2 days. The patient has been receiving normal saline IV at 100 mL/hr, has a nasogastric tube to low suction, and is NPO. Which assessment finding would be a priority for the nurse to report to the health care provider?
a. Oral temperature of 100.1°F
b. Serum sodium level of 138 mEq/L (138 mmol/L)
c. Gradually decreasing level of consciousness (LOC)
d. Weight gain of 2 pounds (1 kg) over the admission weight
ANS: C
The patient’s history and change in LOC could be indicative of fluid and electrolyte disturbances: extracellular fluid (ECF) excess, ECF deficit, hyponatremia, hypernatremia, hypokalemia, or metabolic alkalosis. Further diagnostic information is needed to determine the cause of the change in LOC and the appropriate interventions. The weight gain, elevated temperature, crackles, and serum sodium level also will be reported but do not indicate a need for rapid action to avoid complications.
A nurse is assessing a newly admitted patient with chronic heart failure who forgot to take prescribed medications and seems confused. The patient has peripheral edema and shortness of breath. Which assessment should the nurse complete first?
a. Skin turgor c. Mental status
b. Heart sounds d. Capillary refill
ANS: C
Increases in extracellular fluid (ECF) can lead to swelling of cells in the central nervous system, initially causing confusion, which may progress to coma or seizures. Although skin turgor, capillary refill, and heart sounds may also be affected by increases in ECF, these are signs that do not have as immediate impact on patient outcomes as cerebral edema.
A patient with renal failure who arrives for outpatient hemodialysis is unresponsive to questions and has decreased deep tendon reflexes. Family members report that the patient has been taking aluminum hydroxide/magnesium hydroxide suspension (Maalox) at home for indigestion. Which action should the nurse take first?
a. Notify the patient’s health care provider.
b. Obtain an order to draw a potassium level.
c. Review the last magnesium level on the patient’s chart.
d. Teach the patient about magnesium-containing antacids.
ANS: A
The health care provider should be notified immediately. The patient has a history and manifestations consistent with hypermagnesemia. The nurse should check the chart for a recent serum magnesium level and make sure that blood is sent to the laboratory for immediate electrolyte and chemistry determinations. Dialysis should correct the high magnesium levels. The patient needs teaching about the risks of taking magnesium-containing antacids. Monitoring of potassium levels also is important for patients with renal failure, but the patient’s current symptoms are not consistent with hyperkalemia.
A patient who had a transverse colectomy for diverticulosis 18 hours ago has nasogastric suction. The patient complains of anxiety and incisional pain. The patient’s respiratory rate is 32 breaths/min, and the arterial blood gases (ABGs) indicate respiratory alkalosis. Which action should the nurse take first?
a. Check to make sure the nasogastric tube is patent.
b. Give the patient the PRN IV morphine sulfate 4 mg.
c. Notify the health care provider about the ABG results.
d. Teach the patient how to take slow, deep breaths when anxious.
ANS: B
The patient’s respiratory alkalosis is caused by the increased respiratory rate associated with pain and anxiety. The nurse’s first action should be to medicate the patient for pain. The health care provider may be notified about the ABGs but is likely to instruct the nurse to medicate for pain. The patient will not be able to take slow, deep breaths when experiencing pain. Checking the nasogastric tube can wait until the patient has been medicated for pain.
Which action can the registered nurse (RN) who is caring for a critically ill patient with multiple IV lines and medications delegate to a licensed practical/vocational nurse (LPN/LVN)?
a. Flush a saline lock with normal saline.
b. Verify blood products prior to administration.
c. Remove the patient’s central venous catheter.
d. Titrate the flow rate of vasoactive IV medications.
ANS: A
A LPN/LVN has the education, experience, and scope of practice to flush a saline lock with normal saline. Administration of blood products, adjustment of vasoactive infusion rates, and removal of central catheters in critically ill patients require RN level education and scope of practice
A patient has a serum calcium level of 7.0 mEq/L. Which assessment finding is most important for the nurse to report to the health care provider?
a. The patient is experiencing laryngeal stridor.
b. The patient complains of generalized fatigue.
c. The patient’s bowels have not moved for 4 days.
d. The patient has numbness and tingling of the lips.
ANS: A
Hypocalcemia can cause laryngeal stridor, which may lead to respiratory arrest. Rapid action is required to correct the patient’s calcium level. The other data are also consistent with hypocalcemia, but do not indicate a need for as immediate action as laryngospasm.
Following a thyroidectomy, a patient complains of “a tingling feeling around my mouth.” Which assessment should the nurse complete?
a. Presence of the Chvostek’s sign
b. Abnormal serum potassium level
c. Decreased thyroid hormone level
d. Bleeding on the patient’s dressing
ANS: A
The patient’s symptoms indicate possible hypocalcemia, which can occur secondary to parathyroid injury or removal during thyroidectomy. There is no indication of a need to check the potassium level, the thyroid hormone level, or for bleeding.
A patient is admitted to the emergency department with severe fatigue and confusion. Laboratory studies are done. Which laboratory value will require the most immediate action by the nurse?
a. Arterial blood pH is 7.32.
b. Serum calcium is 18 mg/dL.
c. Serum potassium is 5.1 mEq/L.
d. Arterial oxygen saturation is 91%.
ANS: B
The serum calcium is well above the normal level and puts the patient at risk for cardiac dysrhythmias. The nurse should initiate cardiac monitoring and notify the health care provider. The potassium, oxygen saturation, and pH are also abnormal, and the nurse should notify the health care provider about these values as well, but they are not immediately life threatening.
When assessing a pregnant patient with eclampsia who is receiving IV magnesium sulfate, which finding should the nurse report to the health care provider immediately?
a. The bibasilar breath sounds are decreased.
b. The patellar and triceps reflexes are absent.
c. The patient has been sleeping most of the day.
d. The patient reports feeling “sick to my stomach.”
ANS: B
The loss of the deep tendon reflexes indicates that the patient’s magnesium level may be reaching toxic levels. Nausea and lethargy are also side effects associated with magnesium elevation and should be reported, but they are not as significant as the loss of deep tendon reflexes. The decreased breath sounds suggest that the patient needs to cough and deep breathe to prevent atelectasis.
A patient is receiving a 3% saline continuous IV infusion for hyponatremia. Which assessment data will require the most rapid response by the nurse?
a. The patient’s radial pulse is 105 beats/min.
b. There are crackles throughout both lung fields.
c. There is sediment and blood in the patient’s urine.
d. The blood pressure increases from 120/80 to 142/94 mm Hg.
ANS: B
Crackles throughout both lungs suggest that the patient may be experiencing pulmonary edema, a life-threatening adverse effect of hypertonic solutions. The increased pulse rate and blood pressure and the appearance of the urine should also be reported, but they are not as dangerous as the presence of fluid in the alveoli.
The nurse notes a serum calcium level of 7.9 mg/dL for a patient who has chronic malnutrition. Which action should the nurse take next?
a. Monitor ionized calcium level.
b. Give oral calcium citrate tablets.
c. Check parathyroid hormone level.
d. Administer vitamin D supplements.
ANS: A
This patient with chronic malnutrition is likely to have a low serum albumin level, which will affect the total serum calcium. A more accurate reflection of calcium balance is the ionized calcium level. Most of the calcium in the blood is bound to protein (primarily albumin). Alterations in serum albumin levels affect the interpretation of total calcium levels. Low albumin levels result in a drop in the total calcium level, although the level of ionized calcium is not affected. The other actions may be needed if the ionized calcium is also decreased.
A patient comes to the clinic complaining of frequent, watery stools for the past 2 days. Which action should the nurse take first?
a. Obtain the baseline weight.
b. Check the patient’s blood pressure.
c. Draw blood for serum electrolyte levels.
d. Ask about extremity numbness or tingling.
ANS: B
Because the patient’s history suggests that fluid volume deficit may be a problem, assessment for adequate circulation is the highest priority. The other actions are also appropriate, but are not as essential as determining the patient’s perfusion status.
Which action should the nurse take first when a patient complains of acute chest pain and dyspnea soon after insertion of a centrally inserted IV catheter?
a. Notify the health care provider.
b. Offer reassurance to the patient.
c. Auscultate the patient’s breath sounds.
d. Give prescribed PRN morphine sulfate IV.
ANS: C
The initial action should be to assess the patient further because the history and symptoms are consistent with several possible complications of central line insertion, including embolism and pneumothorax. The other actions may be appropriate, but further assessment of the patient is needed before notifying the health care provider, offering reassurance, or administration of morphine.
After receiving change-of-shift report, which patient should the nurse assess first?
a. Patient with serum potassium level of 5.0 mEq/L who is complaining of abdominal cramping
b. Patient with serum sodium level of 145 mEq/L who has a dry mouth and is asking for a glass of water
c. Patient with serum magnesium level of 1.1 mEq/L who has tremors and hyperactive deep tendon reflexes
d. Patient with serum phosphorus level of 4.5 mg/dL who has multiple soft tissue calcium-phosphate precipitates
ANS: C
The low magnesium level and neuromuscular irritability suggest that the patient may be at risk for seizures. The other patients have mild electrolyte disturbances or symptoms that require action, but they are not at risk for life-threatening complications.
During the admission process, the nurse obtains information about a patient through a physical assessment and diagnostic testing. Based on the data shown in the accompanying figure, which nursing diagnosis is appropriate?
a. Deficient fluid volume c. Risk for injury: seizures
b. Impaired gas exchange d. Risk for impaired skin integrity
ANS: C
The patient’s muscle cramps and low serum calcium level indicate that the patient is at risk for seizures, tetany, or both. The other diagnoses are not supported by the data because the skin turgor is good. The lungs are clear, arterial blood gases are normal, and there is no evidence of edema or dehydration that might suggest that the patient is at risk for impaired skin integrity.
To assess whether there is any improvement in a patient’s dysuria, which question will the nurse ask?
a. “Do you have to urinate at night?”
b. “Do you have blood in your urine?”
c. “Do you have to urinate frequently?”
d. “Do you have pain when you urinate?”
ANS: D
Dysuria is painful urination. The alternate responses are used to assess other urinary tract symptoms: hematuria, nocturia, and frequency.
When a patient’s urine dipstick test indicates a small amount of protein, the nurse’s next action should be to
a. send a urine specimen to the laboratory to test for ketones.
b. obtain a clean-catch urine for culture and sensitivity testing.
c. inquire about which medications the patient is currently taking.
d. ask the patient about any family history of chronic renal failure.
ANS: C
Normally the urinalysis will show zero to trace amounts of protein, but some medications may give false-positive readings. The other actions by the nurse may be appropriate, but checking for medications that may affect the dipstick accuracy should be done first.
A hospitalized patient with possible renal insufficiency after coronary artery bypass surgery is scheduled for a creatinine clearance test. Which item will the nurse need to obtain?
a. Urinary catheter c. Cleansing towelettes
b. Sterile specimen cup d. Large urine container
ANS: D
Because creatinine clearance testing involves a 24-hour urine specimen, the nurse should obtain a large container for the urine collection. Catheterization, cleaning of the perineum with antiseptic towelettes, and a sterile specimen cup are not needed for this test.
A young adult who is employed as a hairdresser and has a 15 pack-year history of cigarette smoking is scheduled for an annual physical examination. The nurse will plan to teach the patient about the increased risk for
a. renal failure. c. pyelonephritis.
b. kidney stones. d. bladder cancer.
ANS: D
Exposure to the chemicals involved with working as a hairdresser and in smoking both increase the risk of bladder cancer, and the nurse should assess whether the patient understands this risk. The patient is not at increased risk for renal failure, pyelonephritis, or kidney stones.
Which medication taken at home by a patient with decreased renal function will be of most concern to the nurse?
a. ibuprofen (Motrin) c. folic acid (vitamin B9)
b. warfarin (Coumadin) d. penicillin (Bicillin C-R)
ANS: A
The nonsteroidal antiinflammatory medications (NSAIDs) are nephrotoxic and should be avoided in patients with impaired renal function. The nurse should also ask about reasons the patient is taking the other medications, but the medication of most concern is the ibuprofen.
A 79-yr-old patient has been admitted with benign prostatic hyperplasia. What is most appropriate to include in the nursing plan of care?
a. Limit fluid intake to no more than 1000 mL/day.
b. Leave a light on in the bathroom during the night.
c. Ask the patient to use a urinal so that urine can be measured.
d. Pad the patient’s bed to accommodate overflow incontinence.
ANS: B
The patient’s age and diagnosis indicate a likelihood of nocturia, so leaving the light on in the bathroom is appropriate. Fluids should be encouraged because dehydration is more common in older patients. The information in the question does not indicate that measurement of the patient’s output is necessary or that the patient has overflow incontinence.
The nurse completing a physical assessment for a newly admitted patient is unable to feel either kidney on palpation. Which action should the nurse take?
a. Obtain a urine specimen to check for hematuria.
b. Document the information on the assessment form.
c. Ask the patient about any history of recent sore throat.
d. Ask the health care provider about scheduling a renal ultrasound.
ANS: B
The kidneys are protected by the abdominal organs, ribs, and muscles of the back and may not be palpable under normal circumstances, so no action except to document the assessment information is needed. Asking about a recent sore throat, checking for hematuria, or obtaining a renal ultrasound may be appropriate when assessing for renal problems for some patients, but there is nothing in the question stem to indicate that they are appropriate for this patient.
How will the nurse assess for flank tenderness in a patient with suspected pyelonephritis?
a. Palpate along both sides of the lumbar vertebral column.
b. Strike a flat hand covering the costovertebral angle (CVA).
c. Push fingers upward into the two lowest intercostal spaces.
d. Percuss between the iliac crest and ribs at the midaxillary line.
ANS: B
Checking for flank pain is best performed by percussion of the CVA and asking about pain. The other techniques would not assess for flank pain.
What glomerular filtration rate (GFR) would the nurse estimate for a 30-yr-old patient with a creatinine clearance result of 60 mL/min?
a. 60 mL/min c. 120 mL/min
b. 90 mL/min d. 180 mL/min
ANS: A
The creatinine clearance approximates the GFR. The other responses are not accurate.
The nurse assessing the urinary system of a 45-yr-old patient would use palpation to
a. determine kidney function. c. check for ureteral peristalsis.
b. identify renal artery bruits. d. assess for bladder distention.
ANS: D
A distended bladder may be palpable above the symphysis pubis. Palpation would not be helpful in assessing for the other listed urinary tract information.
A patient gives the admitting nurse health information before a scheduled intravenous pyelogram (IVP). Which item requires the nurse to intervene before the procedure?
a. The patient has not had food or drink for 8 hours.
b. The patient lists allergies to shellfish and penicillin.
c. The patient complains of costovertebral angle (CVA) tenderness.
d. The patient used a bisacodyl (Dulcolax) tablet the previous night.
ANS: B
Iodine-based contrast dye is used during IVP and for many CT scans. The nurse will need to notify the health care provider before the procedures so that the patient can receive medications such as antihistamines or corticosteroids before the procedures are started. The other information is also important to note and document but does not have immediate implications for the patient’s care during the procedures.
A patient passing bloody urine is scheduled for a cystoscopy with cystogram. Which description of the procedure by the nurse is accurate?
a. “Your doctor will place a catheter into an artery in your groin and inject a dye to visualize the blood supply to the kidneys.”
b. “Your doctor will insert a lighted tube into the bladder, and little catheters will be inserted through the tube into your kidney.”
c. “Your doctor will insert a lighted tube in the bladder through your urethra, inspect the bladder, and instill dye that will outline your bladder on x-ray.”
d. “Your doctor will inject a radioactive solution into a vein in your arm, then the distribution of the isotope in your kidneys and bladder will be visible.”
ANS: C
In a cystoscope and cystogram procedure, a cystoscope is inserted into the bladder for direct visualization, and then contrast solution is injected through the scope so that x-rays can be taken. The response beginning, “Your doctor will place a catheter” describes a renal arteriogram procedure. The response beginning, “Your doctor will inject a radioactive solution” describes a nuclear scan. The response beginning, “Your doctor will insert a lighted tube into the bladder, and little catheters will be inserted” describes a retrograde pyelogram.
The nurse caring for a patient after cystoscopy plans that the patient
a. learns to request narcotics for pain.
b. understands to expect blood-tinged urine.
c. restricts activity to bed rest for 4 to 6 hours.
d. remains NPO for 8 hours to prevent vomiting.
ANS: B
Pink-tinged urine and urinary frequency are expected after cystoscopy. Burning on urination is common, but pain that requires opioids for relief is not expected. A good fluid intake is encouraged after this procedure. Bed rest is not required after cystoscopy.
A patient who has elevated blood urea nitrogen (BUN) and serum creatinine levels is scheduled for a renal arteriogram. Which bowel preparation order would the nurse question for this patient?
a. Fleet enema c. Senna/docusate (Senokot-S)
b. Tap-water enema d. Bisacodyl (Dulcolax) tablets
ANS: A
High-phosphate enemas, such as Fleet enemas, should be avoided in patients with elevated BUN and creatinine because phosphate cannot be excreted by patients with renal failure. The other medications for bowel evacuation are more appropriate.
A female patient with a suspected urinary tract infection (UTI) is to provide a clean-catch urine specimen for culture and sensitivity testing. To obtain the specimen, the nurse will
a. have the patient empty the bladder completely; then obtain the next urine specimen that the patient is able to void.
b. teach the patient to clean the urethral area, void a small amount into the toilet, and then void into a sterile specimen cup.
c. insert a short sterile “mini” catheter attached to a collecting container into the urethra and bladder to obtain the specimen.
d. clean the area around the meatus with a povidone-iodine (Betadine) swab and then have the patient void into a sterile container.
ANS: B
This answer describes the technique for obtaining a clean-catch specimen. The answer beginning, “insert a short, small, ‘mini’ catheter attached to a collecting container” describes a technique that would result in a sterile specimen, but a health care provider’s order for a catheterized specimen would be required. Using Betadine before obtaining the specimen is not necessary and might result in suppressing the growth of some bacteria. The technique described in the answer beginning “have the patient empty the bladder completely” would not result in a sterile specimen.
The nurse is caring for a hospitalized patient with a decreased glomerular filtration rate who is scheduled for an intravenous pyelogram (IVP). Which action will be included in the plan of care?
a. Monitor the urine output after the procedure.
b. Assist with monitored anesthesia care (MAC).
c. Give oral contrast solution before the procedure.
d. Insert a large size urinary catheter before the IVP.
ANS: A
Patients with impaired renal function are at risk for decreased renal function after IVP because the contrast medium used is nephrotoxic, so the nurse should monitor the patient’s urine output. MAC sedation and retention catheterization are not required for the procedure. The contrast medium is given IV, not orally.
Which nursing action is essential for a patient immediately after a renal biopsy?
a. Insert a urinary catheter and test urine for microscopic hematuria.
b. Apply a pressure dressing and keep the patient on the affected side.
c. Check blood glucose to assess for hyperglycemia or hypoglycemia.
d. Monitor blood urea nitrogen (BUN) and creatinine to assess renal function.
ANS: B
A pressure dressing is applied, and the patient is kept on the affected side for 30 to 60 minutes to put pressure on the biopsy side and decrease the risk for bleeding. The blood glucose and BUN/creatinine will not be affected by the biopsy. Although monitoring for hematuria is needed, there is no need for catheterization.
A male patient in the clinic provides a urine sample that is red-orange in color. Which action should the nurse take?
a. Notify the patient’s health care provider.
b. Teach correct midstream urine collection.
c. Ask the patient about current medications.
d. Question the patient about urinary tract infection (UTI) risk factors.
ANS: C
A red-orange color in the urine is normal with some over-the-counter (OTC) medications such as phenazopyridine . The color would not be expected with urinary tract infection, is not a sign that poor technique was used in obtaining the specimen, and does not need to be communicated to the health care provider until further assessment is done.
A female patient being admitted with pneumonia has a history of neurogenic bladder as a result of a spinal cord injury. Which action will the nurse plan to take first?
a. Ask about the usual urinary pattern and any measures used for bladder control.
b. Assist the patient to the toilet at scheduled times to help ensure bladder emptying.
c. Check the patient for urinary incontinence every 2 hours to maintain skin integrity.
d. Use intermittent catheterization on a regular schedule to avoid the risk of infection.
ANS: A
Before planning any interventions, the nurse should complete the assessment and determine the patient’s normal bladder pattern and the usual measures used by the patient at home. All the other responses may be appropriate, but until the assessment is complete, an individualized plan for the patient cannot be developed.
Which information from a patient’s urinalysis requires that the nurse notify the health care provider?
a. pH 6.2 c. WBC 20 to 26/hpf
b. Trace protein d. Specific gravity 1.021
ANS: C
The increased number of white blood cells (WBCs) indicates the presence of urinary tract infection or inflammation. The other findings are normal.
Which statement by a patient who had a cystoscopy the previous day should be reported immediately to the health care provider?
a. “My urine looks pink.” c. “My sleep was restless.”
b. “My IV site is bruised.” d. “My temperature is 101.”
ANS: D
The patient’s elevated temperature may indicate a bladder infection, a possible complication of cystoscopy. The health care provider should be notified so that antibiotic therapy can be started. Pink-tinged urine is expected after a cystoscopy. The insomnia and bruising should be discussed further with the patient but do not indicate a need to notify the health care provider.
When working in the urology/nephrology clinic, which patient could the nurse delegate to an experienced licensed practical/vocational nurse (LPN/LVN)?
a. Patient who is scheduled for a renal biopsy after a recent kidney transplant
b. Patient who will need monitoring for several hours after a renal arteriogram
c. Patient who requires teaching about possible post-cystoscopy complications
d. Patient who will have catheterization to check for residual urine after voiding
ANS: D
LPN/LVN education includes common procedures such as catheterization of stable patients. The other patients require more complex assessments or patient teaching that are included in registered nurse (RN) education and scope of practice.
A 46-yr-old female patient returns to the clinic with recurrent dysuria after being treated with trimethoprim and sulfamethoxazole for 3 days. Which action will the nurse plan to take?
a. Remind the patient about the need to drink 1000 mL of fluids daily.
b. Obtain a midstream urine specimen for culture and sensitivity testing.
c. Suggest that the patient use acetaminophen (Tylenol) to relieve symptoms.
d. Teach the patient to take the prescribed trimethoprim and sulfamethoxazole for 3 more days.
ANS: C
Because uncomplicated urinary tract infections (UTIs) are usually successfully treated with 3 days of antibiotic therapy, this patient will need a urine culture and sensitivity to determine appropriate antibiotic therapy. Acetaminophen would not be as effective as other over-the-counter medications such as phenazopyridine in treating dysuria. The fluid intake should be increased to at least 1800 mL/day. Because the UTI has persisted after treatment with trimethoprim and sulfamethoxazole , the patient is likely to need a different antibiotic.
The nurse determines that instruction regarding prevention of future urinary tract infections (UTIs) has been effective for a 22-yr-old female patient with cystitis when the patient states which of the following?
a. “I can use vaginal antiseptic sprays to reduce bacteria.”
b. “I will drink a quart of water or other fluids every day.”
c. “I will wash with soap and water before sexual intercourse.”
d. “I will empty my bladder every 3 to 4 hours during the day.”
ANS: D
Voiding every 3 to 4 hours is recommended to prevent UTIs. Use of vaginal sprays is discouraged. The bladder should be emptied before and after intercourse, but cleaning with soap and water is not necessary to prevent UTI. A quart of fluids is insufficient to provide adequate urine output to decrease risk for UTI.
Which information will the nurse include when teaching the patient with a urinary tract infection (UTI) about the use of phenazopyridine?
a. Take phenazopyridine for at least 7 days.
b. Phenazopyridine may cause photosensitivity
c. Phenazopyridine may change the urine color
d. Take phenazopyridine before sexual intercourse.
ANS: C
Patients should be taught that phenazopyridine will color the urine deep orange. Urinary analgesics should only be needed for a few days until the prescribed antibiotics decrease the bacterial count. Phenazopyridine does not cause photosensitivity. Taking phenazopyridine before intercourse will not be helpful in reducing the risk for UTI.
Which finding by the nurse will be most helpful in determining whether a 67-yr-old patient with benign prostatic hyperplasia has an upper urinary tract infection (UTI)?
a. Bladder distention c. Suprapubic discomfort
b. Foul-smelling urine d. Costovertebral tenderness
ANS: D
Costovertebral tenderness is characteristic of pyelonephritis. Bladder distention, foul-smelling urine, and suprapubic discomfort are characteristic of a lower UTI and are likely to be present if the patient also has an upper UTI.
The nurse determines that further instruction is needed for a patient with interstitial cystitis when the patient says which of the following?
a. “I should stop having coffee and orange juice for breakfast.”
b. “I will buy calcium glycerophosphate (Prelief) at the pharmacy.”
c. “I will start taking high potency multiple vitamins every morning.”
d. “I should call the doctor about increased bladder pain or foul urine.”
ANS: C
High-potency multiple vitamins may irritate the bladder and increase symptoms. The other patient statements indicate good understanding of the teaching.
To determine possible causes, the nurse will ask a patient admitted with acute glomerulonephritis about
a. recent bladder infection. c. recent sore throat and fever.
b. history of kidney stones. d. history of high blood pressure.
ANS: C
Acute glomerulonephritis frequently occurs after a streptococcal infection such as strep throat. It is not caused by kidney stones, hypertension, or urinary tract infection.
Which finding for a patient admitted with glomerulonephritis indicates to the nurse that treatment has been effective?
a. The patient denies pain with voiding.
b. The urine dipstick is negative for nitrites.
c. The antistreptolysin-O (ASO) titer has decreased.
d. The periorbital and peripheral edema are resolved.
ANS: D
Because edema is a common clinical manifestation of glomerulonephritis, resolution of the edema indicates that the prescribed therapies have been effective. Nitrites will be negative and the patient will not experience dysuria because the patient does not have a urinary tract infection. Antibodies to streptococcus will persist after a streptococcal infection.
The nurse will anticipate teaching a patient with nephrotic syndrome who develops flank pain about treatment with
a. antibiotics. c. anticoagulants.
b. antifungals. d. antihypertensives.
ANS: C
Flank pain in a patient with nephrotic syndrome suggests a renal vein thrombosis and anticoagulation is needed. Antibiotics are used to treat a patient with flank pain caused by pyelonephritis. Fungal pyelonephritis is uncommon and is treated with antifungals. Antihypertensives are used if the patient has high blood pressure.
A 56-yr-old female patient is admitted to the hospital with new-onset nephrotic syndrome. Which assessment data will the nurse expect?
a. Poor skin turgor c. Elevated urine ketones
b. Recent weight gain d. Decreased blood pressure
ANS: B
The patient with a nephrotic syndrome will have weight gain associated with edema. Hypertension is a clinical manifestation of nephrotic syndrome. Skin turgor is normal because of the edema. Urine protein is high. Ketones are not related to nephrotic syndrome.
To prevent recurrence of uric acid renal calculi, the nurse teaches the patient to avoid eating
a. milk and cheese. c. spinach and chocolate.
b. sardines and liver. d. legumes and dried fruit.
ANS: B
Organ meats and fish such as sardines increase purine levels and uric acid. Spinach, chocolate, and tomatoes should be avoided in patients who have oxalate stones. Milk, dairy products, legumes, and dried fruits may increase the incidence of calcium-containing stones.
The nurse teaches an adult patient to prevent the recurrence of renal calculi by
a. using a filter to strain all urine.
b. avoiding dietary sources of calcium.
c. drinking 2000 to 3000 mL of fluid each day.
d. choosing diuretic fluids such as coffee and tea.
ANS: C
A fluid intake of 2000 to 3000 mL/day is recommended to help flush out minerals before stones can form. Avoidance of calcium is not usually recommended for patients with renal calculi. Coffee tends to increase stone recurrence. There is no need for a patient to strain all urine routinely after a stone has passed, and this will not prevent stones.
When planning teaching for a patient with benign nephrosclerosis, the nurse should include instructions regarding
a. preventing bleeding with anticoagulants.
b. monitoring and recording blood pressure.
c. obtaining and documenting daily weights.
d. measuring daily intake and output volumes.
ANS: B
Hypertension is the major manifestation of nephrosclerosis. Measurements of intake and output and daily weights are not necessary unless the patient develops renal insufficiency. Anticoagulants are not used to treat nephrosclerosis.
A 28-yr-old male patient is diagnosed with polycystic kidney disease. Which information is most appropriate for the nurse to include in teaching at this time?
a. Complications of renal transplantation
b. Methods for treating severe chronic pain
c. Options to consider for genetic counseling
d. Differences between hemodialysis and peritoneal dialysis
ANS: C
Because a 28-yr-old patient may be considering having children, the nurse should include information about genetic counseling when teaching the patient. A well-managed patient will not need to choose between hemodialysis and peritoneal dialysis or know about the effects of transplantation for many years. There is no indication that the patient has chronic pain.
A young adult male patient seen at the primary care clinic complains of feeling continued fullness after voiding and a split, spraying urine stream. The nurse will ask about a history of
a. recent kidney trauma. c. recurrent bladder infection.
b. gonococcal urethritis. d. benign prostatic hyperplasia.
ANS: B
The patient’s clinical manifestations are consistent with urethral strictures, a possible complication of gonococcal urethritis. These symptoms are not consistent with benign prostatic hyperplasia, kidney trauma, or bladder infection.
The nurse will plan to teach a 27-yr-old woman who smokes two packs of cigarettes daily about the increased risk for
a. kidney stones. c. bladder infection.
b. bladder cancer. d. interstitial cystitis.
ANS: B
Cigarette smoking is a risk factor for bladder cancer. The patient’s risk for developing interstitial cystitis, urinary tract infection, or kidney stones will not be reduced by quitting smoking
A 68-yr-old female patient admitted to the hospital with dehydration is confused and incontinent of urine. Which nursing action should be included in the plan of care?
a. Restrict fluids between meals and after the evening meal.
b. Insert an indwelling catheter until the symptoms have resolved.
c. Assist the patient to the bathroom every 2 hours during the day.
d. Apply absorbent adult incontinence diapers and pads over the bed linens.
ANS: C
In older or confused patients, incontinence may be avoided by using scheduled toileting times. Indwelling catheters increase the risk for urinary tract infection. Incontinent pads and diapers increase the risk for skin breakdown. Restricting fluids is not appropriate in a patient with dehydration.
A 55-yr-old woman admitted for shoulder surgery asks the nurse for a perineal pad, stating that laughing or coughing causes leakage of urine. Which intervention is most appropriate to include in the care plan?
a. Assist the patient to the bathroom q3hr.
b. Place a commode at the patient’s bedside.
c. Demonstrate how to perform the Credé maneuver.
d. Teach the patient how to perform Kegel exercises.
ANS: D
Kegel exercises to strengthen the pelvic floor muscles will help reduce stress incontinence. The Credé maneuver is used to help empty the bladder for patients with overflow incontinence. Placing the commode close to the bedside and assisting the patient to the bathroom are helpful for functional incontinence.
Following rectal surgery, a patient voids about 50 mL of urine every 30 to 60 minutes for the first 4 hours. Which nursing action is most appropriate?
a. Monitor the patient’s intake and output overnight.
b. Have the patient drink small amounts of fluid frequently.
c. Use an ultrasound scanner to check the postvoiding residual volume.
d. Reassure the patient that this is normal after anesthesia for rectal surgery.
ANS: C
An ultrasound scanner can be used to check for residual urine after the patient voids. Because the patient’s history and clinical manifestations are consistent with overflow incontinence, it is not appropriate to have the patient drink small amounts. Although overflow incontinence is not unusual after surgery, the nurse should intervene to correct the physiologic problem, not just reassure the patient. The patient may develop reflux into the renal pelvis and discomfort from a full bladder if the nurse waits to address the problem for several hours.
A patient admitted to the hospital with pneumonia has a history of functional urinary incontinence. Which nursing action will be included in the plan of care?
a. Demonstrate the use of the Credé maneuver.
b. Teach exercises to strengthen the pelvic floor.
c. Place a bedside commode close to the patient’s bed.
d. Use an ultrasound scanner to check postvoiding residuals.
ANS: C
Modifications in the environment make it easier to avoid functional incontinence. Checking for residual urine and performing the Credé maneuver are interventions for overflow incontinence. Kegel exercises are useful for stress incontinence.
The home health nurse teaches a patient with a neurogenic bladder how to use intermittent catheterization for bladder emptying. Which patient statement indicates that the teaching has been effective?
a. “I will buy seven new catheters weekly and use a new one every day.”
b. “I will use a sterile catheter and gloves for each time I self-catheterize.”
c. “I will clean the catheter carefully before and after each catheterization.”
d. “I will take prophylactic antibiotics to prevent any urinary tract infections.”
ANS: C
Patients who are at home can use a clean technique for intermittent self-catheterization and change the catheter every 7 days. There is no need to use a new catheter every day, to use sterile catheters, or to take prophylactic antibiotics.
After ureterolithotomy, a patient has a left ureteral catheter and a urethral catheter in place. Which action will the nurse include in the plan of care?
a. Provide teaching about home care for both catheters.
b. Apply continuous steady tension to the ureteral catheter.
c. Call the health care provider if the ureteral catheter output drops suddenly.
d. Clamp the ureteral catheter off when output from the urethral catheter stops.
ANS: C
The health care provider should be notified if the ureteral catheter output decreases because obstruction of this catheter may result in an increase in pressure in the renal pelvis. Tension on the ureteral catheter should be avoided to prevent catheter displacement. To avoid pressure in the renal pelvis, the catheter is not clamped. Because the patient is not usually discharged with a ureteral catheter in place, patient teaching about both catheters is not needed.
A 68-yr-old male patient who has bladder cancer had a cystectomy with creation of an Indiana pouch. Which topic will be included in patient teaching?
a. Application of ostomy appliances
b. Barrier products for skin protection
c. Catheterization technique and schedule
d. Analgesic use before emptying the pouch
ANS: C
The Indiana pouch enables the patient to self-catheterize every 4 to 6 hours. There is no need for an ostomy device or barrier products. Catheterization of the pouch is not painful.
A patient who had surgery for creation of an ileal conduit 3 days ago will not look at the stoma and requests that only the ostomy nurse specialist does the stoma care. The nurse identifies a nursing diagnosis of
a. anxiety related to effects of procedure on lifestyle.
b. disturbed body image related to change in function.
c. readiness for enhanced coping related to need for information.
d. self-care deficit (toileting) related to denial of altered body function.
ANS: B
The patient’s unwillingness to look at the stoma or participate in care indicates that disturbed body image is the best way to describe the problem. No data suggest that the impact on lifestyle is a concern for the patient. The patient does not appear to be ready for enhanced coping. The patient’s insistence that only the ostomy nurse care for the stoma indicates that denial is not present.
Which information from a patient who had a transurethral resection with fulguration for bladder cancer 3 days ago is most important to report to the health care provider?
a. The patient is voiding every 4 hours.
b. The patient is using opioids for pain.
c. The patient has seen clots in the urine.
d. The patient is anxious about the cancer.
ANS: C
Clots in the urine are not expected and require further follow-up. Voiding every 4 hours, use of opioids for pain, and anxiety are typical after this procedure.
When preparing a female patient with bladder cancer for intravesical chemotherapy, the nurse will teach about
a. premedicating to prevent nausea.
b. obtaining wigs and scarves to wear.
c. emptying the bladder before the medication.
d. maintaining oral care during the treatments.
ANS: C
The patient will be asked to empty the bladder before instillation of the chemotherapy. Systemic side effects are not usually experienced with intravesical chemotherapy.
Nursing staff on a hospital unit are reviewing rates of health care-associated infections (HAI) of the urinary tract. Which nursing action will be most helpful in decreasing the risk for urinary HAI in patients admitted to the hospital?
a. Testing urine with a dipstick daily for nitrites
b. Avoiding unnecessary urinary catheterizations
c. Encouraging adequate oral fluid and nutritional intake
d. Providing perineal hygiene to patients daily and as needed
ANS: B
Because catheterization bypasses many of the protective mechanisms that prevent urinary tract infection (UTI), avoidance of catheterization is the most effective means of reducing HAI. The other actions will also be helpful but are not as useful as decreasing urinary catheter use.
Which assessment data reported by a patient is consistent with a lower urinary tract infection (UTI)?
a. Low urine output c. Nausea and vomiting
b. Bilateral flank pain d. Burning on urination
ANS: D
Pain with urination is a common symptom of a lower UTI. Urine output does not decrease, but frequency may be experienced. Flank pain and nausea are associated with an upper UTI.
Which assessment finding for a patient who has just been admitted with acute pyelonephritis is most important for the nurse to report to the health care provider?
a. Complaint of flank pain c. Cloudy and foul-smelling urine
b. Blood pressure 90/48 mm Hg d. Temperature 100.1° F (57.8° C)
ANS: B
The low blood pressure indicates that urosepsis and septic shock may be occurring and should be immediately reported. The other findings are typical of pyelonephritis.
A 58-yr-old male patient who is diagnosed with nephrotic syndrome has ascites and 4+ leg edema. Which patient problem is present based on these findings?
a. Activity intolerance c. Disturbed body image
b. Excess fluid volume d. Altered nutrition: less than required
ANS: B
Edema and ascites are evidence of the excess fluid volume. There are no data provided to support the other problems.
A 76-yr-old with benign prostatic hyperplasia (BPH) is agitated and confused, with a markedly distended bladder. Which intervention prescribed by the health care provider should the nurse implement first?
a. Insert a urinary retention catheter.
b. Draw blood for a serum creatinine level.
c. Schedule an intravenous pyelogram (IVP).
d. Administer lorazepam (Ativan) 0.5 mg PO.
ANS: A
The patient’s history and clinical manifestations are consistent with acute urinary retention, and the priority action is to relieve the retention by catheterization. The BUN and creatinine measurements can be obtained after the catheter is inserted. The patient’s agitation may resolve after the bladder distention is corrected, and sedative drugs should be used cautiously in older patients. The IVP may be used as a diagnostic test but does not need to be done urgently.
Which nursing action is of highest priority for a patient with renal calculi who is being admitted to the hospital with gross hematuria and severe colicky left flank pain?
a. Administer prescribed analgesics.
b. Monitor temperature every 4 hours.
c. Encourage increased oral fluid intake.
d. Give antiemetics as needed for nausea.
ANS: A
Although all of the nursing actions may be used for patients with renal lithiasis, the patient’s presentation indicates that management of pain is the highest priority action. If the patient has urinary obstruction, increasing oral fluids may increase the symptoms. There is no evidence of infection or nausea.
The nurse is caring for a patient who has had an ileal conduit for several years. Which nursing action could be delegated to unlicensed assistive personnel (UAP)?
a. Change the ostomy appliance.
b. Choose the appropriate ostomy bag.
c. Monitor the appearance of the stoma.
d. Assess for possible urinary tract infection (UTI).
ANS: A
Changing the ostomy appliance for a stable patient could be done by UAP. Assessments of the site, choosing the appropriate ostomy bag, and assessing for UTI symptoms require more education and scope of practice and should be done by the registered nurse (RN).
Which assessment finding is most important to report to the health care provider regarding a patient who has had left-sided extracorporeal shock wave lithotripsy?
a. Blood in urine c. Left flank discomfort
b. Left flank bruising d. Decreased urine output
ANS: D
Because lithotripsy breaks the stone into small sand, which could cause obstruction, it is important to report a drop in urine output. Left flank pain, bruising, and hematuria are common after lithotripsy.
A patient is unable to void after having an open loop resection and fulguration of the bladder. Which nursing action should be implemented?
a. Assist the patient to soak in a 15-minute sitz bath.
b. Restrict oral fluids to equal previous urine volume.
c. Insert a straight urethral catheter and drain the bladder.
d. Teach the patient how to do isometric perineal exercises.
ANS: A
Sitz baths will relax the perineal muscles and promote voiding. The patient should be to drink fluids. Kegel exercises are helpful in the prevention of incontinence, but would not be helpful for a patient experiencing retention. Catheter insertion increases the risk for urinary tract infection and should be avoided when possible
The nurse observes unlicensed assistive personnel (UAP) taking the following actions when caring for a patient with a urethral catheter. Which action requires that the nurse intervene?
a. Taping the catheter to the skin on the patient’s upper inner thigh
b. Cleaning around the patient’s urinary meatus with soap and water
c. Disconnecting the catheter from the drainage tube to obtain a specimen
d. Using an alcohol-based gel hand cleaner before performing catheter care
ANS: C
The catheter should not be disconnected from the drainage tube because this increases the risk for urinary tract infection. The other actions are appropriate and do not require any intervention
A 48-yr-old male patient who weighs 242 lb (110 kg) undergoes a nephrectomy for massive kidney trauma from a motor vehicle crash. Which postoperative assessment finding is most important to communicate to the surgeon?
a. Blood pressure is 102/58.
b. Urine output is 20 mL/hr for 2 hours.
c. Incisional pain level is reported as 9/10.
d. Crackles are heard at bilateral lung bases.
ANS: B
Because the urine output should be at least 0.5 mL/kg/hr, a 40-mL output for 2 hours indicates that the patient may have decreased renal perfusion because of bleeding, inadequate fluid intake, or obstruction at the suture site. The blood pressure requires ongoing monitoring but does not indicate inadequate perfusion at this time. The patient should cough and deep breathe, but the crackles do not indicate a need for an immediate change in therapy. The incisional pain should be addressed, but this is not as potentially life threatening as decreased renal perfusion. In addition, the nurse can medicate the patient for pain.
A patient had a cystectomy with an ileal conduit yesterday. Which new assessment data is most important for the nurse to communicate to the health care provider?
a. Cloudy appearing urine c. Heart rate 102 beats/minute
b. Hypotonic bowel sounds d. Continuous stoma drainage
ANS: C
Tachycardia may indicate infection, hemorrhage, or hypovolemia, which are all serious complications of this surgery. The urine from an ileal conduit normally contains mucus and is cloudy. Hypotonic bowel sounds are expected after bowel surgery. Continuous drainage of urine from the stoma is normal.
A patient with a history of polycystic kidney disease is admitted to the surgical unit after having shoulder surgery. Which of the routine postoperative orders is most important for the nurse to discuss with the health care provider?
a. Give ketorolac 10 mg PO PRN for pain.
b. Infuse 5% dextrose in normal saline at 75 mL/hr.
c. Order regular diet after patient is awake and alert.
d. Draw blood urea nitrogen (BUN) and creatinine in 2 hours.
ANS: A
The nonsteroidal antiinflammatory drugs (NSAIDs) should be avoided in patients with decreased renal function because nephrotoxicity is a potential adverse effect. The other orders do not need any clarification or change.
A patient seen in the clinic for a bladder infection describes the following symptoms. Which information is most important for the nurse to report to the health care provider?
a. Urinary urgency c. Intermittent hematuria
b. Left-sided flank pain d. Burning with urination
ANS: B
Flank pain indicates that the patient may have developed pyelonephritis as a complication of the bladder infection. The other clinical manifestations are consistent with a lower urinary tract infection.
A patient in the urology clinic is diagnosed with monilial urethritis. Which action will the nurse include in the plan of care?
a. Teach the patient about the use of antifungal medications.
b. Tell the patient to avoid tub baths until the symptoms resolve.
c. Instruct the patient to refer recent sexual partners for treatment.
d. Teach the patient to avoid nonsteroidal antiinflammatory drugs (NSAIDs).
ANS: A
Monilial urethritis is caused by a fungus and antifungal medications such as nystatin or fluconazole are usually used as treatment. Because monilial urethritis is not sexually transmitted, there is no need to refer sexual partners. Warm baths and NSAIDS may be used to treat symptoms.
Which action will the nurse anticipate taking for an otherwise healthy 50-yr-old who has just been diagnosed with stage 1 renal cell carcinoma?
a. Prepare patient for a renal biopsy.
b. Provide preoperative teaching about nephrectomy.
c. Teach the patient about chemotherapy medications.
d. Schedule for a follow-up appointment in 3 months.
ANS: B
The treatment of choice in patients with localized renal tumors who have no co-morbid conditions is partial or total nephrectomy. A renal biopsy will not be needed in a patient who has already been diagnosed with renal cancer. Chemotherapy is used for metastatic renal cancer. Because renal cell cancer frequently metastasizes, treatment will be started as soon as possible after the diagnosis.
Which information about a patient with Goodpasture syndrome requires the most rapid action by the nurse?
a. Blood urea nitrogen level is 70 mg/dL.
b. Urine output over the last 2 hours is 30 mL.
c. Audible crackles bilaterally over the posterior chest to the midscapular level.
d. Elevated level of antiglomerular basement membrane (anti-GBM) antibodies.
ANS: C
Crackles heard to a high level indicate a need for rapid actions such as assessment of O2 saturation, reporting the findings to the health care provider, initiating O2 therapy, and dialysis. The other findings will also be reported but are typical of Goodpasture syndrome and do not require immediate nursing action.
A patient is admitted to the emergency department with possible renal trauma after an automobile accident. Which prescribed intervention will the nurse implement first?
a. Check blood pressure and heart rate.
b. Administer morphine sulfate 4 mg IV.
c. Transport to radiology for an intravenous pyelogram.
d. Insert a urethral catheter and obtain a urine specimen.
ANS: A
Because the kidney is very vascular, the initial action with renal trauma will be assessment for bleeding and shock. The other actions are also important after the patient’s cardiovascular status has been determined and stabilized.
After change-of-shift report, which patient should the nurse assess first?
a. Patient with a urethral stricture who has not voided for 12 hours
b. Patient who has cloudy urine after orthotopic bladder reconstruction
c. Patient with polycystic kidney disease whose blood pressure is 186/98 mm Hg
d. Patient who voided bright red urine immediately after returning from lithotripsy
ANS: A
The patient information suggests acute urinary retention, which is a medical emergency. The nurse will need to assess the patient and consider whether to insert a retention catheter. The other patients will also be assessed, but their findings are consistent with their diagnoses and do not require immediate assessment or possible intervention.
A patient has been diagnosed with urinary tract calculi that are high in uric acid. Which foods will the nurse teach the patient to avoid (select all that apply)?
a. Milk
b. Liver
c. Spinach
d. Chicken
e. Cabbage
f. Chocolate
ANS: B, D
Meats contain purines, which are metabolized to uric acid. The other foods might be restricted in patients who have calcium or oxalate stones.
After the insertion of an arteriovenous graft (AVG) in the right forearm, a patient complains of pain and coldness of the right fingers. Which action should the nurse take?
a. Teach the patient about normal AVG function.
b. Remind the patient to take a daily low-dose aspirin tablet.
c. Report the patient’s symptoms to the health care provider.
d. Elevate the patient’s arm on pillows to above the heart level.
ANS: C
The patient’s complaints suggest the development of distal ischemia (steal syndrome) and may require revision of the AVG. Elevation of the arm above the heart will further decrease perfusion. Pain and coolness are not normal after AVG insertion. Aspirin therapy is not used to maintain grafts.
When a patient with acute kidney injury (AKI) has an arterial blood pH of 7.30, the nurse will expect an assessment finding of
a. persistent skin tenting c. hot, flushed face and neck.
b. rapid, deep respirations. d. bounding peripheral pulses.
ANS: B
Patients with metabolic acidosis caused by AKI may have Kussmaul respirations as the lungs try to regulate carbon dioxide. Bounding pulses and vasodilation are not associated with metabolic acidosis. Because the patient is likely to have fluid retention, poor skin turgor would not be a finding in AKI.
The nurse is planning care for a patient with severe heart failure who has developed elevated blood urea nitrogen (BUN) and creatinine levels. The primary treatment goal in the plan will be
a. augmenting fluid volume. c. diluting nephrotoxic substances.
b. maintaining cardiac output. d. preventing systemic hypertension.
ANS: B
The primary goal of treatment for acute kidney injury (AKI) is to eliminate the cause and provide supportive care while the kidneys recover. Because this patient’s heart failure is causing AKI, the care will be directed toward treatment of the heart failure. For renal failure caused by hypertension, hypovolemia, or nephrotoxins, the other responses would be correct.
A patient who has acute glomerulonephritis is hospitalized with hyperkalemia. Which information will the nurse monitor to evaluate the effectiveness of the prescribed calcium gluconate IV?
a. Urine volume c. Cardiac rhythm
b. Calcium level d. Neurologic status
ANS: C
The calcium gluconate helps prevent dysrhythmias that might be caused by the hyperkalemia. The nurse will monitor the other data as well, but these will not be helpful in determining the effectiveness of the calcium gluconate.
Which statement by a patient with stage 5 chronic kidney disease (CKD) indicates that the nurse’s teaching about management of CKD has been effective?
a. “I need to get most of my protein from low-fat dairy products.”
b. “I will increase my intake of fruits and vegetables to 5 per day.”
c. “I will measure my urinary output each day to help calculate the amount I can drink.”
d. “I need to take erythropoietin to boost my immune system and help prevent infection.”
ANS: C
The patient with end-stage renal disease is taught to measure urine output as a means of determining an appropriate oral fluid intake. Erythropoietin is given to increase the red blood cell count and will not offer any benefit for immune function. Dairy products are restricted because of the high phosphate level. Many fruits and vegetables are high in potassium and should be restricted in the patient with CKD.
Which information will the nurse monitor in order to determine the effectiveness of prescribed calcium carbonate (Caltrate) for a patient with chronic kidney disease (CKD)?
a. Blood pressure c. Neurologic status
b. Phosphate level d. Creatinine clearance
ANS: B
Calcium carbonate is prescribed to bind phosphorus and prevent mineral and bone disease in patients with CKD. The other data will not be helpful in evaluating the effectiveness of calcium carbonate.
Sodium polystyrene sulfonate (Kayexalate) is ordered for a patient with hyperkalemia. Before administering the medication, the nurse should assess the
a. bowel sounds. c. blood urea nitrogen (BUN).
b. blood glucose. d. level of consciousness (LOC).
ANS: A
Sodium polystyrene sulfonate (Kayexalate) should not be given to a patient with a paralytic ileus (as indicated by absent bowel sounds) because bowel necrosis can occur. The BUN and creatinine, blood glucose, and LOC would not affect the nurse’s decision to give the medication.
Which menu choice by the patient who is receiving hemodialysis indicates that the nurse’s teaching has been successful?
a. Split-pea soup, English muffin, and nonfat milk
b. Oatmeal with cream, half a banana, and herbal tea
c. Poached eggs, whole-wheat toast, and apple juice
d. Cheese sandwich, tomato soup, and cranberry juice
ANS: C
Poached eggs would provide high-quality protein, and apple juice is low in potassium. Cheese is high in salt and phosphate, and tomato soup is high in potassium. Split-pea soup is high in potassium, and dairy products are high in phosphate. Bananas are high in potassium, and cream is high in phosphate.
Before administration of calcium carbonate to a patient with chronic kidney disease (CKD), the nurse should check laboratory results for
a. potassium level. c. serum phosphate.
b. total cholesterol. d. serum creatinine.
ANS: C
If serum phosphate is elevated, the calcium and phosphate can cause soft tissue calcification. Calcium carbonate should not be given until the phosphate level is lowered. Total cholesterol, creatinine, and potassium values do not affect whether calcium carbonate should be administered
A 37-yr-old female patient is hospitalized with acute kidney injury (AKI). Which information will be most useful to the nurse in evaluating improvement in kidney function?
a. Urine volume c. Glomerular filtration rate (GFR)
b. Creatinine level d. Blood urea nitrogen (BUN) level
ANS: C
GFR is the preferred method for evaluating kidney function. BUN levels can fluctuate based on factors such as fluid volume status and protein intake. Urine output can be normal or high in patients with AKI and does not accurately reflect kidney function. Creatinine alone is not an accurate reflection of renal function.
A patient will need vascular access for hemodialysis. Which statement by the nurse accurately describes an advantage of a fistula over a graft?
a. A fistula is much less likely to clot.
b. A fistula increases patient mobility.
c. A fistula can accommodate larger needles.
d. A fistula can be used sooner after surgery.
ANS: A
Arteriovenous (AV) fistulas are much less likely to clot than grafts, although it takes longer for them to mature to the point where they can be used for dialysis. The choice of an AV fistula or a graft does not have an impact on needle size or patient mobility.
When caring for a patient with a left arm arteriovenous fistula, which action will the nurse include in the plan of care to maintain the patency of the fistula?
a. Auscultate for a bruit at the fistula site.
b. Assess the quality of the left radial pulse.
c. Compare blood pressures in the left and right arms.
d. Irrigate the fistula site with saline every 8 to 12 hours.
ANS: A
The presence of a thrill and bruit indicates adequate blood flow through the fistula. Pulse rate and quality are not good indicators of fistula patency. Blood pressures should never be obtained on the arm with a fistula. Irrigation of the fistula might damage the fistula, and typically only dialysis staff would access the fistula.
A patient who has had progressive chronic kidney disease (CKD) for several years has just begun regular hemodialysis. Which information about diet will the nurse include in patient teaching?
a. Increased calories are needed because glucose is lost during hemodialysis.
b. More protein is allowed because urea and creatinine are removed by dialysis.
c. Dietary potassium is not restricted because the level is normalized by dialysis.
d. Unlimited fluids are allowed because retained fluid is removed during dialysis.
ANS: B
When the patient is started on dialysis and nitrogenous wastes are removed, more protein in the diet is encouraged. Fluids are still restricted to avoid excessive weight gain and complications such as shortness of breath. Glucose is not lost during hemodialysis. Sodium and potassium intake continues to be restricted to avoid the complications associated with high levels of these electrolytes.
Which action by a patient who is using peritoneal dialysis (PD) indicates that the nurse should provide more teaching about PD?
a. The patient leaves the catheter exit site without a dressing.
b. The patient plans 30 to 60 minutes for a dialysate exchange.
c. The patient cleans the catheter while taking a bath each day.
d. The patient slows the inflow rate when experiencing abdominal pain.
ANS: C
Patients are encouraged to take showers rather than baths to avoid infections at the catheter insertion side. The other patient actions indicate good understanding of peritoneal dialysis.
