TEST 9: The Client with Urinary Tract Health Problems

Question 1

The Client with Cancer of the Bladder
1. A client has undergone a cystectomy and an ileal conduit diversion. What should the nurse
incorporate into the discharge instructions? Select all that apply.
1. Drink at least 3,000 mL of fluid each day.
2. Minimize daily activities.
3. Keep urine alkaline to prevent urinary tract infections.
4. Avoid odor-producing foods, such as onions, fish, eggs, and cheese.
5. Wear snug clothing over the stoma to encourage urine flow into the drainage bag.

Answer 1

The Client with Cancer of the Bladder
1. 1, 4. An adequate fluid intake aids in the prevention of urinary calculi and infection. Odor-
producing foods can produce offensive odors that may impact the client’s lifestyle and relationships.
Lack of activity leads to urinary stasis, which promotes urinary calculi development and infection.
Acidic urine helps prevent urinary tract infections. Tight clothing over the stoma obstructs blood
circulation and urine flow.
CN: Reduction of risk potential; CL: Synthesize

Question 2

2. A nurse is caring for a client with an ileal conduit. When assessing the stoma, which of the
   following outcomes are not desirable? Select all that apply.
3. Dermatitis.
4. Bleeding.
5. Fungal infection.
6. Use of adhesive solvent on the skin around the stoma.
7. Placing skin cement on the faceplate of the collection bag

Answer 2

2. 1, 2, 3. Dermatitis with alkaline encrustations may occur when alkaline urine comes in contact
   with exposed skin. Yeast infections (or fungal infections) are another common peristomal skin
   problem. If the stoma is irritated from rubbing, there will be bleeding. The nurse and client should
   avoid irritating the stoma. Adhesive solvent should be used on a gauze pad to remove old adhesive
   and should, therefore not contact the stoma directly. Only a minimal amount of skin cement is applied
   to the faceplate of the collection bag and skin to secure the appliance over the stoma, so obstruction
   of the stoma by the cement would not be possible if correct technique is followed.
   CN: Physiological adaptation; CL: Evaluate

Question 3

3. A client is admitted to the recovery room after cystoscopy with biopsy. Before the nurse can
   discharge the client, the nurse should be sure the client:
4. Has a bowel movement.
5. Has received the first dose of pain medication.
6. Has voided.
7. Has no blood in the urine.

Answer 3

3. 3. The nurse should verify that the client has voided prior to discharge in order to evaluate
      bladder function. Bowel function is not expected to be affected by this procedure. There may not be a
      need for pain medication immediately post procedure and before discharge, but the nurse should
      assess the client’s pain status and inform the client about the use and side effects of the medication. It
      is normal for the client to have hematuria because of the procedure.
      CN: Management of care; CL: Synthesize

Question 4

4. The nurse should assess the client with bladder cancer for which of the following?
5. Suprapubic pain.
6. Dysuria.
7. Painless hematuria.
8. Urine retention.

Answer 4

4. 3. Painless hematuria is the most common clinical finding in bladder cancer. Other symptoms
      include urinary frequency, dysuria, and urinary urgency, but these are not as common as hematuria.
      Suprapubic pain and urine retention do not occur in bladder cancer.
      CN: Physiological adaptation; CL: Analyze

Question 5

5. A client is to have a cystoscopy. Which of the following indicate that the client has developed
a complication after the cystoscopy?
1. Dizziness.
2. Chills.
3. Pink-tinged urine.
4. Bladder spasms.

Answer 5

5. 2. Chills could indicate the onset of acute infection that can progress to septic shock. Dizziness
      would not be an anticipated symptom after a cystoscopy. Pink-tinged urine and bladder spasms are
      common after cystoscopy.
      CN: Reduction of risk potential; CL: Analyze

Question 6

6. If the client develops lower abdominal pain after a cystoscopy, the nurse should instruct the
client to do which of the following?
1. Apply an ice pack to the pubic area.
2. Massage the abdomen gently.
3. Ambulate as much as possible.
4. Sit in a tub of warm water.

Answer 6

6. 4. Lower abdominal pain after a cystoscopy is frequently caused by bladder spasms. Warm
      water can help relax muscles. Ice is not effective in relieving spasms. Massage and ambulation mayincrease bladder irritability.
      CN: Basic care and comfort; CL: Synthesize

Question 7

7. A client who has been diagnosed with bladder cancer is scheduled for an ileal conduit.
   Preoperatively, the nurse reinforces the client’s understanding of the surgical procedure by explainingthat an ileal conduit:
8. Is a temporary procedure that can be reversed later.
9. Diverts urine into the sigmoid colon, where it is expelled through the rectum.
10. Conveys urine from the ureters to a stoma opening on the abdomen.
11. Creates an opening in the bladder that allows urine to drain into an external pouch.

Answer 7

7. 3. An ileal conduit is a permanent urinary diversion in which a portion of the ileum is
      surgically resected and one end of the segment is closed. The ureters are surgically attached to this
      segment of the ileum, and the open end of the ileum is brought to the skin surface on the abdomen to
      form the stoma. The client must wear a pouch to collect the urine that continually flows through the
      conduit. The bladder is removed during the surgical procedure and the ileal conduit is not reversible.
      Diversion of urine to the sigmoid colon is called a ureteroileosigmoidostomy. An opening in the
      bladder that allows urine to drain externally is called a cystostomy.
      CN: Reduction of risk potential; CL: Apply

Question 8

8. After surgery for an ileal conduit, the nurse should closely assess the client for the occurrence
   of which of the following complications related to pelvic surgery?
9. Peritonitis.
10. Thrombophlebitis.
11. Ascites.
12. Inguinal hernia.

Answer 8

8. 2. After pelvic surgery, there is an increased chance of thrombophlebitis owing to the pelvic
      manipulation that can interfere with circulation and promote venous stasis. Peritonitis is a potential
      complication of any abdominal surgery, not just pelvic surgery. Ascites is most frequently an
      indication of liver disease. Inguinal hernia may be caused by an increase in intra-abdominal pressure
      or a congenital weakness of the abdominal wall; ventral hernia occurs at the site of a previous
      abdominal incision.
      CN: Reduction of risk potential; CL: Analyze

Question 9

9. The nurse is assessing the urine of a client who has had an ileal conduit and notes that the urine
   is yellow with a moderate amount of mucus. Based on these data, the nurse should:
10. Change the appliance bag.
11. Notify the physician.
12. Obtain a urine specimen for culture.
13. Encourage a high fluid intake.

Answer 9

9. 4. Mucus is secreted by the intestinal segment used to create the conduit and is a normal
      occurrence. The client should be encouraged to maintain a large fluid intake to help flush the mucus
      out of the conduit. Because mucus in the urine is expected, it is not necessary to change the appliance
      bag or to notify the physician. The mucus is not an indication of an infection, so a urine culture is not
      necessary.
      CN: Reduction of risk potential; CL: Synthesize

Question 10

10. When teaching the client to care for an ileal conduit, the nurse instructs the client to empty the
    appliance frequently. Which of the following indicate that the client is following instructions?
11. The skin around the stoma is red.
12. The urine is a deep yellow.
13. There is no odor present.
14. The seal around the stoma is intact.

Answer 10

10. 4. If the appliance becomes too full, it is likely to pull away from the skin completely or to
       leak urine onto the skin; thus if the seal is intact, the client is emptying the appliance regularly. The
       skin around the seal should not be red or irritated, which could indicate a leak. There will likely be
       an odor from the urine. Deep yellow urine indicates that the client should be increasing fluid intake.
       CN: Physiological adaptation; CL: Evaluate

Question 11

11. The nurse should teach the client with an ileal conduit to prevent urine leakage when changing
    the appliance by using which of the following procedures?
12. Insert a gauze wick into the stoma.
13. Close the opening temporarily with a cellophane seal.
14. Suction the stoma before changing the appliance.
15. Avoid oral fluids for several hours before changing the appliance.

Answer 11

11. 1. Inserting a gauze wick into the stoma helps prevent urine leakage when changing the
       appliance. The stoma should not be sealed or suctioned. Oral fluids do not need to be avoided.
       CN: Physiological adaptation; CL: Synthesize

Question 12

12. The client with an ileal conduit will be using a reusable appliance at home. The nurse should
    teach the client to clean the appliance routinely with which product?
13. Baking soda.
14. Soap.
15. Hydrogen peroxide.
16. Alcohol.

Answer 12

12. 2. A reusable appliance should be routinely cleaned with soap and water.
       CN: Physiological adaptation; CL: Apply

Question 13

13. The nurse is evaluating the discharge teaching for a client who has an ileal conduit. Which of
    the following statements indicates that the client has correctly understood the teaching? Select all that
    apply.
14. “If I limit my fluid intake, I will not have to empty my ostomy pouch as often.”
15. “I can place an aspirin tablet in my pouch to decrease odor.”
16. “I can usually keep my ostomy pouch on for 3 to 7 days before changing it.”
17. “I must use a skin barrier to protect my skin from urine.”5. “I should empty my ostomy pouch of urine when it is full.”

Answer 13

13. 3, 4. The client with an ileal conduit must learn self-care activities related to care of the
    stoma and ostomy appliances. The client should be taught to increase fluid intake to about 3,000
    mL/day and should not limit intake. Adequate fluid intake helps to flush mucus from the ileal conduit.
    The ostomy appliance should be changed approximately every 3 to 7 days and whenever a leak
    develops. A skin barrier is essential to protecting the skin from the irritation of the urine. An aspirin
    should not be used as a method of odor control because it can be an irritant to the stoma and lead to
    ulceration. The ostomy pouch should be emptied when it is one-third to one-half full to prevent theweight of the urine from pulling the appliance away from the skin.
    CN: Reduction of risk potential; CL: Evaluate

Question 14

14. A client has an ileal conduit. Which of the following solutions will be useful to help control
    odor in the urine collecting bag after it has been cleaned?
15. Salt water.
16. Vinegar.
17. Ammonia.
18. Bleach.

Answer 14

14. 2. A distilled vinegar solution acts as a good deodorizing agent after an appliance has been
       cleaned well with soap and water. If the client prefers, a commercial deodorizer may be used. Salt
       solution does not deodorize. Ammonia and bleaching agents may damage the appliance.
       CN: Basic care and comfort; CL: Apply

Question 15

15. A female client who has a urinary diversion tells the nurse, “This urinary pouch is
    embarrassing. Everyone will know that I’m not normal. I don’t see how I can go out in public
    anymore. ” The most appropriate nursing goal for this client is to:
16. Manage her anxiety about her health.
17. Learn how to care for the urinary diversion.
18. Overcome feelings of worthlessness.
19. Express fears about the urinary diversion.

Answer 15

15. 4. It is normal for clients to express fears and concerns about the body changes associated
       with a urinary diversion. Allowing the client time to verbalize concerns in a supportive environment
       and suggesting that she discuss these concerns with people who have successfully adjusted to ostomy
       surgery can help her begin coping with these changes in a positive manner. Although the client may be
       anxious about this situation and may be feeling worthless, the underlying problem is a disturbance in
       body image. There are no data to indicate that the client does not know how to care for the urinary
       diversion.
       CN: Psychosocial integrity; CL: Analyze

Question 16

16. The nurse teaches the client with a urinary diversion to attach the appliance to a standard
    urine collection bag at night. The most important reason for doing this is to prevent:
17. Urine reflux into the stoma.
18. Appliance separation.
19. Urine leakage.
20. The need to restrict fluids.

Answer 16

16. 1. The most important reason for attaching the appliance to a standard urine collection bag at
       night is to prevent urine reflux into the stoma and ureters, which can result in infection. Use of a
       standard collection bag also keeps the appliance from separating from the skin and helps prevent
       urine leakage from an overly full bag, but the primary purpose is to prevent reflux of urine. A client
       with a urinary diversion should drink 2,000 to 3,000 mL of fluid each day; it would be inappropriate
       to suggest decreasing fluid intake.
       CN: Physiological adaptation; CL: Apply

Question 17

17. The nurse is teaching the client with an ileal conduit how to prevent a urinary tract infection.
    Which of the following measures would be most effective?
18. Avoid people with respiratory tract infections.
19. Maintain a daily fluid intake of 2,000 to 3,000 mL.
20. Use sterile technique to change the appliance.
21. Irrigate the stoma daily.

Answer 17

17. 2. Maintaining a fluid intake of 2,000 to 3,000 mL/day is likely to be most effective in
       preventing urinary tract infection. A high fluid intake results in high urine output, which prevents
       urinary stasis and bacterial growth. Avoiding people with respiratory tract infections will not prevent
       urinary tract infections. Clean, not sterile, technique is used to change the appliance. An ileal conduit
       stoma is not irrigated.
       CN: Physiological adaptation; CL: Synthesize

Question 18

18. The nurse evaluates the effectiveness of the client’s postoperative plan of care. Which of the
    following would be an expected outcome for a client with an ileal conduit?
19. The client verbalizes the understanding that physical activity must be curtailed.
20. The client will place an aspirin in the drainage pouch to help control odor.
21. The client demonstrates how to catheterize the stoma.
22. The client will empty the drainage pouch frequently throughout the day.

Answer 18

18. 4. It is important that the client empty the drainage pouch throughout the day to decrease the
       risk of leakage. The client does not normally need to curtail physical activity. Aspirin should never be
       placed in a pouch because aspirin can irritate or ulcerate the stoma. The client does not catheterize an
       ileal conduit stoma.
       CN: Physiological adaptation; CL: Evaluate

Question 19

19. A client is scheduled to undergo weekly intravesical chemotherapy for bladder cancer for the
    next 8 weeks. Which of the following indicates that the client understands how to manage the urine as
    a biohazard. The client will:
20. Void into a bedpan and then empty the urine into the toilet.
21. Disinfect the urine and toilet with bleach for 6 hours following a treatment.
22. Clean the bathroom daily with disinfectant wipes.
23. Use a separate bathroom from the rest of the family for the next 8 weeks

Answer 19

19. 2. After intravesical chemotherapy, the client must treat the urine as a biohazard; this involves
       disinfecting the urine and the toilet with household bleach for 6 hours following a treatment. It is not
       necessary to use a bedpan and then empty the urine in the toilet; the client can use the toilet, but must
       disinfect the urine with bleach. The bathroom does not need to be cleaned daily with disinfectant
       wipes. The client does not need to use a separate bathroom as long as the client’s urine is disinfected
       with bleach.
       CN: Physiological integrity; CL: Evaluate

Question 20

20. A nurse is planning care for a client who underwent a percutaneous needle biopsy of the
    kidney. What should the nurse plan to do immediately after the biopsy? Select all that apply.
21. Assess the biopsy site.
22. Take vital signs every hour.
23. Assess urine for hematuria.
24. Place the client in a prone position.
25. Assess the client for chest pain.

Answer 20

20. 1, 3, 4. The nurse should assess the biopsy site for bleeding and hematoma formation. Theclient should remain prone for 8 to 24 hours after the biopsy. A pressure dressing will aid in blood
    coagulation. Vital signs assessment should be taken every 5 to 15 minutes for the first hour and then
    less often if the client is stable. The urine does not need to be collected and kept on ice. The nurse
    should collect serial urine specimens to assess for hematuria. A renal biopsy does not put the client at
    increased risk for chest pain.
    CN: Reduction of risk potential; CL: Synthesize

Question 21

The Client with Renal Calculi
21. A client has renal colic due to renal lithiasis. What is the nurse’s first priority in managing
care for this client?
1. Do not allow the client to ingest fluids.
2. Encourage the client to drink at least 500 mL of water each hour.
3. Request the central supply department to send supplies for straining urine.
4. Administer an opioid analgesic as prescribed.

Answer 21

The Client with Renal Calculi
21. 4. If infection or blockage caused by calculi is present, a client can experience sudden severe
pain in the flank area, known as renal colic. Pain from a kidney stone is considered an emergency
situation and requires analgesic intervention. Withholding fluids will make urine more concentrated
and stones more difficult to pass naturally. Forcing large quantities of fluid may cause hydronephrosis
if urine is prevented from flowing past calculi. Straining urine for small stones is important, but does
not take priority over pain management.
CN: Management of care; CL: Synthesize

Question 22

22. A client is admitted to the hospital with a diagnosis of renal calculi. The client is
    experiencing severe flank pain and nausea; the temperature is 100.6°F (38.1°C). Which of the
    following would be a priority outcome for this client?
23. Prevention of urinary tract complications.
24. Alleviation of nausea.
25. Alleviation of pain.
26. Maintenance of fluid and electrolyte balance.

Answer 22

22. 3. The priority nursing goal for this client is to alleviate the pain, which can be excruciating.
       Prevention of urinary tract complications and alleviation of nausea are appropriate throughout the
       client’s hospitalization, but relief of the severe pain is a priority. The client is at little risk for fluid
       and electrolyte imbalance.
       CN: Physiological adaptation; CL: Synthesize

Question 23

23. The client is scheduled to have a kidney, ureter, and bladder (KUB) radiograph. To prepare
    the client for this procedure, the nurse should explain to the client that:
24. Fluid and food will be withheld the morning of the examination.
25. A tranquilizer will be given before the examination.
26. An enema will be given before the examination.
27. No special preparation is required for the examination.

Answer 23

23. 4. A KUB radiographic examination ordinarily requires no preparation. It is usually done
       while the client lies supine and does not involve the use of radiopaque substances.
       CN: Reduction of risk potential; CL: Apply

Question 24

24. In addition to nausea and severe flank pain, a female client with renal calculi has pain in the
    groin and bladder. The nurse should assess the client further for signs of:
25. Nephritis.
26. Referred pain.
27. Urine retention.
28. Additional stone formation.

Answer 24

24. 2. The pain associated with renal colic due to calculi is commonly referred to the groin and
       bladder in female clients and to the testicles in male clients. Nausea, vomiting, abdominal cramping,
       and diarrhea may also be present. Nephritis or urine retention is an unlikely cause of the referred
       pain. The type of pain described in this situation is unlikely to be caused by additional stone
       formation.
       CN: Physiological adaptation; CL: Analyze

Question 25

25. Which of the following nursing interventions is likely to provide the most relief from the pain
    associated with renal colic?
26. Applying moist heat to the flank area.
27. Administering meperidine (Demerol).
28. Encouraging high fluid intake.
29. Maintaining complete bed rest.

Answer 25

25. 2. During episodes of renal colic, the pain is excruciating. It is necessary to administer opioid
       analgesics to control the pain. Application of heat, encouraging high fluid intake, and limitation of
       activity are important interventions, but they will not relieve the renal colic pain.
       CN: Reduction of risk potential; CL: Synthesize

Question 26

26. A client who has been diagnosed with renal calculi reports that the pain is intermittent and
    less colicky. Which of the following nursing actions is most important at this time?
27. Report hematuria to the physician.
28. Strain the urine carefully.
29. Administer meperidine (Demerol) every 3 hours.
30. Apply warm compresses to the flank area.

Answer 26

26. 2. Intermittent pain that is less colicky indicates that the calculi may be moving along the
       urinary tract. Fluids should be encouraged to promote movement, and the urine should be strained to
       detect passage of the stone. Hematuria is to be expected from the irritation of the stone. Analgesics
       should be administered when the client needs them, not routinely. Moist heat to the flank area is
       helpful when renal colic occurs, but it is less necessary as pain is lessened.
       CN: Physiological adaptation; CL: Synthesize

Question 27

27. The client is scheduled for an intravenous pyelogram (IVP) to determine the location of the
    renal calculi. Which of the following measures would be most important for the nurse to include inpretest preparation?
28. Ensuring adequate fluid intake on the day of the test.
29. Preparing the client for the possibility of bladder spasms during the test.
30. Checking the client’s history for allergy to iodine.
31. Determining when the client last had a bowel movement.

Answer 27

27. 3. A client scheduled for an IVP should be assessed for allergies to iodine and shellfish.Clients with such allergies may be allergic to the IVP dye and be at risk for an anaphylactic reaction.
       Adequate fluid intake is important after the examination. Bladder spasms are not common during an
       IVP. Bowel preparation is important before an IVP to allow visualization of the ureters and bladder,
       but checking for allergies is most important.
       CN: Reduction of risk potential; CL: Synthesize

Question 28

28. After an intravenous pyelogram (IVP), the nurse should anticipate incorporating which of the
    following measures into the client’s plan of care?
29. Maintaining bed rest.
30. Encouraging adequate fluid intake.
31. Assessing for hematuria.
32. Administering a laxative.

Answer 28

28. 2. After an IVP, the nurse should encourage fluids to decrease the risk of renal complications
       caused by the contrast agent. There is no need to place the client on bed rest or administer a laxative.
       An IVP would not cause hematuria.
       CN: Reduction of risk potential; CL: Synthesize

Question 29

29. A client has a ureteral catheter in place after renal surgery. A priority nursing action for care
    of the ureteral catheter is to:
30. Irrigate the catheter with 30 mL of normal saline every 8 hours.
31. Ensure that the catheter is draining freely.
32. Clamp the catheter every 2 hours for 30 minutes.
33. Ensure that the catheter drains at least 30 mL/h.

Answer 29

29. 2. The ureteral catheter should drain freely without bleeding at the site. The catheter is rarely
       irrigated, and any irrigation would be done by the physician. The catheter is never clamped. The
       client’s total urine output (ureteral catheter plus voiding or indwelling urinary catheter output) should
       be at least 30 mL/h.
       CN: Reduction of risk potential; CL: Synthesize

Question 30

30. Which of the following interventions would be the most appropriate for preventing the
    development of a paralytic ileus in a client who has undergone renal surgery?
31. Encourage the client to ambulate every 2 to 4 hours.
32. Offer 3 to 4 oz (90 to 120 mL) of a carbonated beverage periodically.
33. Encourage use of a stool softener.
34. Continue IV fluid therapy.

Answer 30

30. 1. Ambulation stimulates peristalsis. A client with paralytic ileus is kept on nothing-by-mouth
       status until peristalsis returns. Carbonated beverages will increase gas and distention but will not
       stimulate peristalsis. A stool softener will not stimulate peristalsis. IV fluid infusion is a routine
       postoperative prescription that does not have any effect on preventing paralytic ileus.
       CN: Physiological adaptation; CL: Synthesize

Question 31

31. The nurse is conducting a postoperative assessment of a client on the first day after renal
    surgery. Which of the following findings would be most important for the nurse to report to the
    physician?
32. Temperature, 99.8°F (37.7°C).
33. Urine output, 20 mL/h.
34. Absence of bowel sounds.
35. A 2′′ × 2′′ area of serosanguineous drainage on the flank dressing.

Answer 31

31. 2. The decrease in urine output may reflect inadequate renal perfusion and should be reported
       immediately. Urine output of 30 mL/h or greater is considered acceptable. A slight elevation in
       temperature is expected after surgery. Peristalsis returns gradually, usually the second or third day
       after surgery. Bowel sounds will be absent until then. A small amount of serosanguineous drainage is
       to be expected.
       CN: Physiological adaptation; CL: Analyze

Question 32

32. A client with a history of renal calculi formation is being discharged after surgery to remove
    the calculus. What instructions should the nurse include in the client’s discharge teaching plan?
33. Increase daily fluid intake to at least 2 to 3 L.
34. Strain urine at home regularly.
35. Eliminate dairy products from the diet.
36. Follow measures to alkalinize the urine.

Answer 32

32. 1. A high daily fluid intake is essential for all clients who are at risk for calculi formation
       because it prevents urinary stasis and concentration, which can cause crystallization. Depending on
       the composition of the stone, the client also may be instructed to institute specific dietary measures
       aimed at preventing stone formation. Clients may need to limit purine, calcium, or oxalate. Urine may
       need to be either alkaline or acid. There is no need to strain urine regularly.
       CN: Basic care and comfort; CL: Synthesize

Question 33

33. Because a client’s renal stone was found to be composed of uric acid, a low-purine, alkaline-
    ash diet was prescribed. Incorporation of which of the following food items into the home diet would
    indicate that the client understands the necessary diet modifications?
34. Milk, apples, tomatoes, and corn.
35. Eggs, spinach, dried peas, and gravy.
36. Salmon, chicken, caviar, and asparagus.4. Grapes, corn, cereals, and liver.

Answer 33

33. 1. Because a high-purine diet contributes to the formation of uric acid, a low-purine diet is
       advocated. An alkaline-ash diet is also advocated because uric acid crystals are more likely to
       develop in acid urine. Foods that may be eaten as desired in a low-purine diet include milk, all fruits,
       tomatoes, cereals, and corn. Foods allowed on an alkaline-ash diet include milk, fruits (except
       cranberries, plums, and prunes), and vegetables (especially legumes and green vegetables). Gravy,
       chicken, and liver are high in purine.
       CN: Basic care and comfort; CL: Evaluate

Question 34

34. Allopurinol (Zyloprim), 200 mg/day, is prescribed for the client with renal calculi to take at
    home. The nurse should teach the client about which of the following adverse effects of this
    medication?
35. Retinopathy.
36. Maculopapular rash.
37. Nasal congestion.
38. Dizziness.

Answer 34

34. 2. Allopurinol (Zyloprim) is used to treat renal calculi composed of uric acid. Adverse
       effects of allopurinol include drowsiness, maculopapular rash, anemia, abdominal pain, nausea,vomiting, and bone marrow depression. Clients should be instructed to report rashes and unusual
       bleeding or bruising. Retinopathy, nasal congestion, and dizziness are not adverse effects of
       allopurinol.
       CN: Pharmacological and parenteral therapies; CL: Synthesize

Question 35

35. A client has been prescribed allopurinol (Zyloprim) for renal calculi that are caused by high
uric acid levels. Which of the following indicate the client is experiencing adverse effect(s) of this
drug? Select all that apply.
1. Nausea.
2. Rash.
3. Constipation.
4. Flushed skin.
5. Bone marrow depression.

Answer 35

35. 1, 2, 5. Common adverse effects of allopurinol (Zyloprim) include gastrointestinal distress,
    such as anorexia, nausea, vomiting, and diarrhea. A rash is another potential adverse effect. A
    potentially life-threatening adverse effect is bone marrow depression. Constipation and flushed skin
    are not associated with this drug.
    CN: Pharmacological and parenteral therapies; CL: Analyze

Question 36

36. The nurse is reviewing laboratory reports for a client who is taking allopurinol (Zyloprim).
    Which of the following indicate that the drug has had a therapeutic effect?
37. Decreased urine alkaline phosphatase level.
38. Increased urine calcium excretion.
39. Increased serum calcium level.
40. Decreased serum uric acid level.

Answer 36

36. 4. By inhibiting uric acid synthesis, allopurinol (Zyloprim) decreases its excretion. The drug’s
       effectiveness is assessed by evaluating for a decreased serum uric acid concentration. Allopurinol
       does not alter the level of alkaline phosphatase, nor does it affect urine calcium excretion or the
       serum calcium level.
       CN: Pharmacological and parenteral therapies; CL: Evaluate

Question 37

37. A client is to receive peritoneal dialysis. To prepare for the procedure, the nurse should:
38. Assess the dialysis access for a bruit and thrill.
39. Insert an indwelling urinary catheter and drain all urine from the bladder.
40. Ask the client to turn toward the left side.
41. Warm the solution in the warmer.

Answer 37

The Client with Acute Renal Failure
37. 4. Solution for peritoneal dialysis should be warmed to body temperature in a warmer or with
a heating pad; do not use the microwave. Cold dialysate increases discomfort. Assessment for a bruit
and thrill is necessary with hemodialysis when the client has a fistula, graft, or shunt. An indwelling
urinary catheter is not required for this procedure. The nurse should position the client in a supine or
low Fowler’s position.
CN: Reduction of risk potential; CL: Synthesize

Question 38

38. A client has been admitted with acute renal failure. What should the nurse do? Select all that
    apply.
39. Elevate the head of the bed 30 to 45 degrees.
40. Take vital signs.
41. Establish an IV access site.
42. Call the admitting physician for prescriptions.
43. Contact the hemodialysis unit.

Answer 38

38. 1, 2, 3, 4. Elevation of the head of the bed will promote ease of breathing. Respiratory
    manifestations of acute renal failure include shortness of breath, orthopnea, crackles, and the potential
    for pulmonary edema. Therefore, priority is placed on facilitation of respiration. The nurse should
    assess the vital signs because the pulse and respirations will be elevated. Establishing a site for IV
    therapy will become important because fluids will be administered IV in addition to orally. The
    physician will need to be contacted for further prescriptions; there is no need to contact the
    hemodialysis unit.
    CN: Physiological adaptation; CL: Synthesize

Question 39

39. Which of the following is the most common initial manifestation of acute renal failure?
40. Dysuria.
41. Anuria.
42. Hematuria.
43. Oliguria.

Answer 39

39. 4. Oliguria is the most common initial symptom of acute renal failure. Anuria is rarely the
       initial symptom. Dysuria and hematuria are not associated with acute renal failure.
       CN: Physiological adaptation; CL: Analyze

Question 40

40. A client developed cardiogenic shock after a severe myocardial infarction and has now
    developed acute renal failure. The client’s family asks the nurse why the client has developed acute
    renal failure. The nurse should base the response on the knowledge that there was:
41. A decrease in the blood flow through the kidneys.
42. An obstruction of urine flow from the kidneys.
43. A blood clot formed in the kidneys.
44. Structural damage to the kidney resulting in acute tubular necrosis

Answer 40

40. 1. There are three categories of acute renal failure: prerenal, intrarenal, and postrenal. Causes
       of prerenal failure occur outside the kidney and include poor perfusion and decreased circulating
       volume resulting from such factors as trauma, septic shock, impaired cardiac function, and
       dehydration. In this case of severe myocardial infarction, there was a decrease in perfusion of the
       kidneys caused by impaired cardiac function. An obstruction within the urinary tract, such as from
       kidney stones, tumors, or benign prostatic hypertrophy, is called postrenal failure. Structural damage
       to the kidney resulting from acute tubular necrosis is called intrarenal failure. It is caused by such
       conditions as hypersensitivity (allergic disorders), renal vessel obstruction, and nephrotoxic agents.CN: Physiological adaptation; CL: Apply

Question 41

41. The client who is in acute renal failure has an elevated blood urea nitrogen (BUN). What is
the likely cause of this finding?
1. Fluid retention.
2. Hemolysis of red blood cells.
3. Below-normal metabolic rate.
4. Reduced renal blood flow.

Answer 41

41. 4. Urea, an end product of protein metabolism, is excreted by the kidneys. Impairment in renal
       function caused by reduced renal blood flow results in an increase in the plasma urea level. Fluid
       retention, hemolysis of red blood cells, and lowered metabolic rate do not cause an elevated BUN
       value.
       CN: Reduction of risk potential; CL: Analyze

Question 42

42. The client’s serum potassium level is elevated in acute renal failure, and the nurse
    administers sodium polystyrene sulfonate (Kayexalate). This drug acts to:
43. Increase potassium excretion from the colon.
44. Release hydrogen ions for sodium ions.
45. Increase calcium absorption in the colon.
46. Exchange sodium for potassium ions in the colon.

Answer 42

42. 4. Polystyrene sulfonate, a cation-exchange resin, causes the body to excrete potassium
       through the gastrointestinal tract. In the intestines, particularly the colon, the sodium of the resin is
       partially replaced by potassium. The potassium is then eliminated when the resin is eliminated with
       feces. Although the result is to increase potassium excretion, the specific method of action is the
       exchange of sodium ions for potassium ions. Polystyrene sulfonate does not release hydrogen ions or
       increase calcium absorption.
       CN: Pharmacological and parenteral therapies; CL: Apply

Question 43

43. A client with acute renal failure has an increase in the serum potassium level. The nurse
should monitor the client for:
1. Cardiac arrest.2. Pulmonary edema.
3. Circulatory collapse.
4. Hemorrhage.

Answer 43

43. 1. Hyperkalemia places the client at risk for serious cardiac arrhythmias and cardiac arrest.
       Therefore, the nurse should carefully monitor the client for cardiac arrhythmias and be prepared to
       treat cardiac arrest when caring for a client with hyperkalemia. Increased potassium levels do not
       result in pulmonary edema, circulatory collapse, or hemorrhage.
       CN: Pharmacological and parenteral therapies; CL: Analyze

Question 44

44. A high-carbohydrate, low-protein diet is prescribed for the client with acute renal failure.
The intended outcome of this diet is to:
1. Act as a diuretic.
2. Reduce demands on the liver.
3. Help maintain urine acidity.
4. Prevent the development of ketosis.

Answer 44

44. 4. High-carbohydrate foods meet the body’s caloric needs during acute renal failure. Protein is
       limited because its breakdown may result in accumulation of toxic waste products. The main goal of
       nutritional therapy in acute renal failure is to decrease protein catabolism. Protein catabolism causes
       increased levels of urea, phosphate, and potassium. Carbohydrates provide energy and decrease the
       need for protein breakdown. They do not have a diuretic effect. Some specific carbohydrates
       influence urine pH, but this is not the reason for encouraging a high-carbohydrate, low-protein diet.
       There is no need to reduce demands on the liver through dietary manipulation in acute renal failure.
       CN: Basic care and comfort; CL: Apply

Question 45

45. The client with acute renal failure asks the nurse for a snack. Because the client’s potassium
    level is elevated, which of the following snacks is most appropriate?
46. A gelatin dessert.
47. Yogurt.
48. An orange.
49. Peanuts.

Answer 45

45. 1. Gelatin desserts contain little or no potassium and can be served to a client on a potassium-
       restricted diet. Foods high in potassium include bran and whole grains; most dried, raw, and frozen
       fruits and vegetables; most milk and milk products; chocolate, nuts, raisins, coconut, and strong
       brewed coffee.
       CN: Basic care and comfort; CL: Apply

Question 46

46. In the oliguric phase of acute renal failure, the nurse should assess the client for:
47. Pulmonary edema.
48. Metabolic alkalosis.
49. Hypotension.
50. Hypokalemia.

Answer 46

46. 1. Pulmonary edema can develop during the oliguric phase of acute renal failure because of
       decreased urine output and fluid retention. Metabolic acidosis develops because the kidneys cannot
       excrete hydrogen ions, and bicarbonate is used to buffer the hydrogen. Hypertension may develop as a
       result of fluid retention. Hyperkalemia develops as the kidneys lose the ability to excrete potassium.
       CN: Physiological adaptation; CL: Analyze

Question 47

47. The client in acute renal failure has an external cannula inserted in the forearm for
    hemodialysis. Which of the following nursing measures is appropriate for the care of this client?
48. Use the unaffected arm for blood pressure measurements.
49. Draw blood from the cannula for routine laboratory work.
50. Percuss the cannula for bruits each shift.
51. Inject heparin into the cannula each shift.

Answer 47

47. 1. The unaffected arm should be used for blood pressure measurement. The external cannula
       must be handled carefully and protected from damage and disruption. In addition, a tourniquet or
       clamps should be kept at the bedside because dislodgment of the cannula would cause arterial
       hemorrhage. The arm with the cannula is not used for blood pressure measurement, IV therapy, orvenipuncture. Patency is assessed by auscultating for bruits every shift. Heparin is not injected into
       the cannula to maintain patency. Because it is part of the general circulation, the cannula cannot be
       heparinized.
       CN: Reduction of risk potential; CL: Synthesize

Question 48

48. During the first hemodialysis treatment, the client develops a headache, confusion, and
    nausea. The nurse should assess the client further for:
49. Disequilibrium syndrome.
50. Myocardial infarction.
51. Air embolism.
52. Peritonitis.

Answer 48

48. 1. Common symptoms of disequilibrium syndrome include headache, nausea and vomiting,
       confusion, and even seizures. Disequilibrium syndrome typically occurs near the end or after the
       completion of hemodialysis treatment. It is the result of rapid changes in solute composition and
       osmolality of the extracellular fluid. These symptoms are not related to cardiac function, air
       embolism, or peritonitis.
       CN: Reduction of risk potential; CL: Analyze

Question 49

49. During dialysis, the client has disequilibrium syndrome. The nurse should first:
50. Administer oxygen per nasal cannula.
51. Slow the rate of dialysis.
52. Reassure the client that the symptoms are normal.
53. Place the client in Trendelenburg’s position.

Answer 49

49. 2. If disequilibrium syndrome occurs during dialysis, the most appropriate intervention is to
       slow the rate of dialysis. The syndrome is believed to result from too-rapid removal of urea and
       excess electrolytes from the blood; this causes transient cerebral edema, which produces the
       symptoms. Administration of oxygen and position changes do not affect the symptoms. It would not be
       appropriate to reassure the client that the symptoms are normal.
       CN: Reduction of risk potential; CL: Synthesize

Question 50

50. The client receives heparin while receiving hemodialysis. The nurse explains the rationale
    supporting anticoagulation by making which of the following statements?
51. “Regional anticoagulation is achieved by putting heparin in the dialysis machine and protamine
    sulfate, which reverses the anticoagulation, in the client.”
52. “You will receive warfarin sodium (Coumadin) to maintain anticoagulation betweentreatments.”
53. “Heparin does not enter the body, so there is no risk of bleeding.”
54. “Clotting time is seriously prolonged for several hours after each treatment.”

Answer 50

50. 1. Regional anticoagulation can be achieved by infusing heparin in the dialyzer and protamine
       sulfate, its antagonist, in the client. Warfarin sodium (Coumadin) is not used in dialysis treatment.
       There is some risk of bleeding; however, clotting time is monitored carefully. The client’s clotting
       time will not be seriously affected, although some rebound effect may occur.
       CN: Pharmacological and parenteral therapies; CL: Apply

Question 51

51. Which of the following abnormal blood values would not be improved by dialysis treatment?
52. Elevated serum creatinine level.
53. Hyperkalemia.
54. Decreased hemoglobin concentration.
55. Hypernatremia.

Answer 51

51. 3. Dialysis has no effect on anemia. Because some red blood cells are injured during the
       procedure, dialysis aggravates a low hemoglobin concentration. Dialysis will clear metabolic waste
       products from the body and correct electrolyte imbalances.
       CN: Reduction of risk potential; CL: Apply

Question 52

52. The nurse teaches the client how to recognize infection in the shunt by telling the client to
assess the shunt each day for:
1. Absence of a bruit.
2. Sluggish capillary refill time.
3. Coolness of the involved extremity.
4. Swelling at the shunt site.

Answer 52

52. 4. Signs and symptoms of an external access shunt infection include redness, tenderness,
       swelling, and drainage from around the shunt site. The absence of a bruit indicates closing of the
       shunt. Sluggish capillary refill time and coolness of the extremity indicate decreased blood flow to
       the extremity.
       CN: Reduction of risk potential; CL: Analyze

Question 53

53. The client with acute renal failure is recovering and asks the nurse, “Will my kidneys ever
    function normally again?” The nurse’s response is based on knowledge that the client’s renal status
    will most likely:
54. Continue to improve over a period of weeks.
55. Result in the need for permanent hemodialysis.
56. Improve only if the client receives a renal transplant.
57. Result in end-stage renal failure.

Answer 53

53. 1. The kidneys have a remarkable ability to recover from serious insult. Recovery may take 3
       to 12 months. The client should be taught how to recognize the signs and symptoms of decreasing
       renal function and to notify the physician if such problems occur. In a client who is recovering from
       acute renal failure, there is no need for renal transplantation or permanent hemodialysis. Chronic
       renal failure develops before end-stage renal failure.
       CN: Physiological adaptation; CL: Apply

Question 54

The Client with Urinary Tract Infection
54. The nurse is teaching an older adult with a urinary tract infection about the importance of
increasing fluids in the diet. Which of the following puts this client at a risk for not obtaining
sufficient fluids?
1. Diminished liver function.
2. Increased production of antidiuretic hormone.
3. Decreased production of aldosterone.
4. Decreased ability to detect thirst.

Answer 54

The Client with Urinary Tract Infection
54. 4. The sensation of thirst diminishes in those greater than 60 years of age; hence, fluid intake
is decreased and dissolved particles in the extracellular fluid compartment become moreconcentrated. There is no change in liver function in older adults, nor is there a reduction of ADH and
aldosterone as a normal part of aging.
CN: Physiological adaptation; CL: Apply

Question 55

55. A client with a urinary tract infection is to take nitrofurantoin four times each day. The client
    asks the nurse, “What should I do if I forget a dose?” What should the nurse tell the client?
56. “You can wait and take the next dose when it is due.”
57. “Double the amount prescribed with your next dose.”
58. “Take the prescribed dose as soon as you remember it, and if it is very close to the time for the
    next dose, delay that next dose.”
59. “Take a lot of water with a double amount of your prescribed dose.”

Answer 55

55. 3. Antibiotics have the maximum effect when the level of the medication in the blood is
       maintained. However, because nitrofurantoin is readily absorbed from the gastrointestinal tract and is
       primarily excreted in urine, toxicity may develop by doubling the dose. The client should not skip a
       dose, if one dose is missed. Additional fluids, especially water, should be encouraged, but not forced
       to promote elimination of the antibiotic from the body. Adequate fluid intake aids in the prevention of
       urinary tract infections, in addition to an acidic urine.
       CN: Pharmacological and parenteral therapies; CL: Synthesize

Question 56

56. To prevent catheter associated urinary tract infection the nurse should do which of the
    following? Select all that apply.
57. Change the catheter daily.
58. Provide perineal care several times a day.
59. Assess the client for signs of infection.
60. Encourage the client to drink 3,000 mL fluids daily.
61. Recommend the health care provider prescribe antibiotics.

Answer 56

56. 2, 3, 4. Catheter-acquired urinary tract infection is the most frequent type of health care-
acquired infection (HAI), and represents as much as 80% of HAIs in hospitals. The nurse should
provide meticulous perineal care, encourage the client to obtain an adequate fluid intake, and assess
the client for signs of infection such as an elevated temperature. It is not necessary to change the
catheter daily. It is recommended that long term use of an indwelling urinary catheter be evaluated
carefully and other methods considered, if the catheter will be in place longer than 2 weeks. It is not
necessary to request a prescription for antibiotics as the client does not currently have an infection.
CN: Safety and infection control; CL: Synthesize

Question 57

57. A nurse is assessing a client with a urinary tract infection who takes an antihypertensive drug.
    The nurse reviews the client’s urinalysis results (see chart). The nurse should:

LABORATORY RESULTS
pH 6.8
RBC  3 per high power field
Color Yellow
Spec Gravity 1.030

1. Encourage the client to increase fluid intake.
2. Withhold the next dose of antihypertensive medication.
3. Restrict the client’s sodium intake.
4. Encourage the client to eat at least half of a banana per day.

Answer 57

57. 1. The client’s urine specific gravity is elevated. Specific gravity is a reflection of the
       concentrating ability of the kidneys. This level indicates that the urine is concentrated. By increasing
       fluid intake, the urine will become more dilute. Antihypertensives do not make urine more
       concentrated unless there is a diuretic component within them. The nurse should not hold a dose of
       antihypertensive medication. Sodium tends to pull water with it; by restricting sodium, less water, not
       more, will be present. Bananas do not aid in the dilution of urine.
       CN: Reduction of risk potential; CL: Synthesize

Question 58

58. A client has nephropathy. The physician prescribes a 24-hour urine collection for creatinine
    clearance. Which of the following actions is necessary to ensure proper collection of the specimen?
59. Collect the urine in a preservative-free container and keep it on ice.2. Inform the client to discard the last voided specimen at the conclusion of urine collection.
60. Obtain a self-report of the client’s weight before beginning the collection of urine.
61. Request a prescription for insertion of an indwelling urinary catheter.

Answer 58

58. 1. All urine for creatinine clearance determination must be saved in a container with no
       preservatives and refrigerated or kept on ice. The first urine voided at the beginning of the collection
       is discarded, not the last. A self-report of weight may not be accurate. It is not necessary to have an
       indwelling urinary catheter inserted for urine collection.
       CN: Reduction of risk potential; CL: Apply

Question 59

A client who weighs 207 lb (94.1 kg) is to receive 1.5 mg/kg of gentamicin sulfate (Garamycin) IV
three times each day. How many milligrams of medication should the nurse administer for each dose?
Round to the nearest whole number.
_________________ mg.

Answer 59

59. 141 mg

CN: Pharmacological and parenteral therapies; CL: Apply

Question 60

60. A 24-year-old female client comes to an ambulatory care clinic in moderate distress with a
    probable diagnosis of acute cystitis. When obtaining the client’s history, the nurse should ask the
    client if she has had:
61. Fever and chills.
62. Frequency and burning on urination.
63. Flank pain and nausea.
64. Hematuria.

Answer 60

60. 2. The classic symptoms of cystitis are severe burning on urination, urgency, and frequent
       urination. Systemic symptoms, such as fever and nausea and vomiting, are more likely to accompany
       pyelonephritis than cystitis. Hematuria may occur, but it is not as common as frequency and burning.
       CN: Physiological adaptation; CL: Analyze

Question 61

61. The client asks the nurse, “How did I get this urinary tract infection?” The nurse should
    explain that in most instances, cystitis is caused by:
62. Congenital strictures in the urethra.
63. An infection elsewhere in the body.
64. Urinary stasis in the urinary bladder.
65. An ascending infection from the urethra.

Answer 61

61. 4. Although various conditions may result in cystitis, the most common cause is an ascending
       infection from the urethra. Strictures and urine retention can lead to infections, but these are not the
       most common cause. Systemic infections are rarely causes of cystitis.
       CN: Physiological adaptation; CL: Apply

Question 62

62. The client, who is a newlywed, is afraid to discuss her diagnosis of cystitis with her husband.
    Which would be the nurse’s best approach?
63. Arrange a meeting with the client, her husband, the physician, and the nurse.
64. Insist that the client talk with her husband because good communication is necessary for a
    successful marriage.
65. Talk first with the husband alone and then with both of them together to share the husband’s
    reactions.
66. Spend time with the client addressing her concerns and then stay with her while she talks with
    her husband.

Answer 62

62. 4. As newlyweds, the client and her husband need to develop a strong communication base.
       The nurse can facilitate communication by preparing and supporting the client. Given the situation, an
       interdisciplinary conference is inappropriate and would not promote intimacy for the client and her
       husband. Insisting that the client talk with her husband is not addressing her fears. Being present
       allows the nurse to facilitate the discussion of a difficult topic. Having the nurse speak first with the
       husband alone shifts responsibility away from the couple.
       CN: Psychosocial integrity; CL: Synthesize

Question 63

63. The nurse teaches a female client who has cystitis methods to relieve her discomfort until the
    antibiotic takes effect. Which of the following responses by the client would indicate that she
    understands the nurse’s instructions?
64. “I will place ice packs on my perineum.”
65. “I will take hot tub baths.”
66. “I will drink a cup of warm tea every hour.”
67. “I will void every 5 to 6 hours.”

Answer 63

63. 2. Hot tub baths promote relaxation and help relieve urgency, discomfort, and spasm.
       Applying heat to the perineum is more helpful than cold because heat reduces inflammation. Although
       liberal fluid intake should be encouraged, caffeinated beverages, such as tea, coffee, and cola, can be
       irritating to the bladder and should be avoided. Voiding at least every 2 to 3 hours should be
       encouraged because it reduces urinary stasis.
       CN: Basic care and comfort; CL: Evaluate

Question 64

64. The client with first-time bacterial cystitis is being treated with an antibiotic to be taken for 7
    days. The nurse should instruct the client to:
65. Limit fluids to 1,000 mL/day.
66. Notify the health care provider when the urine is clear.
67. Take the entire prescription as ordered.
68. Use condoms if having sex.

Answer 64

64. 3. The client should take the prescription as ordered. The client should increase fluid intake to
       3,000 mL/day to increase urination. Even though the urine may become clear in a short period, it is
       not necessary to notify the health care provider. The client should continue to take the entire
       prescription of antibiotics. Cystitis is not sexually transmitted, so protection by using a condom is not
       necessary.
       CN: Pharmacological and parenteral therapies; CL: Synthesize

Question 65

65. When teaching the client with a urinary tract infection about taking a prescribed antibiotic for
7 days, the nurse should tell the client to report which of the following to the health care provider?
Select all that apply.
1. Cloudy urine for the first few days.
2. Blood in the urine.
3. Rash.
4. Mild nausea.
5. Fever above 100°F (37.8°C)
6. Urinating every 3 to 4 hours

Answer 65

65. 2, 3, 4. The nurse should instruct the client to report signs of adverse reaction to the antibiotic
    or indications that the urinary tract infection is not clearing. Blood in the urine is not an expected
    outcome, rash is an adverse response to the antibiotic, and an elevated temperature indicates a
    persistent infection. These signs should be reported to the health care provider. Cloudy urine can be
    expected during the first few days of antibiotic treatment. Mild nausea is a side effect of antibiotic
    therapy, but can be managed with eating small, frequent meals. Urinating every 3 to 4 hours or more is
    expected, particularly if the client is increasing the fluid intake as directed.
    CN: Pharmacological and parenteral therapies; CL: Synthesis

Question 66

66. A client has been prescribed nitrofurantoin for treatment of a lower urinary tract infection.
    Which of the following instructions should the nurse include when teaching the client about this
    medication? Select all that apply.
67. “Take the medication on an empty stomach.”
68. “Your urine may become brown in color.”
69. “Increase your fluid intake.”
70. “Take the medication until your symptoms subside.”
71. “Take the medication with an antacid to decrease gastrointestinal distress.”

Answer 66

66. 2, 3. Clients who are taking nitrofurantoin should be instructed to take the medication with
    meals and to increase their fluid intake to minimize gastrointestinal distress. The urine may become
    brown in color. Although this change is harmless, clients need to be prepared for this color change.
    The client should be instructed to take the full prescription and not to stop taking the drug because
    symptoms have subsided. The medication should not be taken with antacids as this may interfere with
    the drug’s absorption.
    CN: Pharmacological and parenteral therapies; CL: Synthesize

Question 67

Nitrofurantoin, 75 mg four times per day, has been prescribed for a client with a lower urinary tract
infection. The medication comes in an oral suspension of 25 mg/5 mL. How many milliliters should
the nurse administer for each dose?
_______________________ mL.

Answer 67

67. 15 mL
    The following formula is used to calculate the correct dosage:
    CN: Pharmacological and parenteral therapies; CL: Apply

Question 68

68. Which of the following statements by a female client would indicate that she is at high risk
    for a recurrence of cystitis?
69. “I can usually go 8 to 10 hours without needing to empty my bladder.”
70. “I take a tub bath every evening.”
71. “I wipe from front to back after voiding.”
72. “I drink a lot of water during the day.”

Answer 68

68. 1. Stasis of urine in the bladder is one of the chief causes of bladder infection, and a client
       who voids infrequently is at greater risk for reinfection. A tub bath does not promote urinary tract
       infections as long as the client avoids harsh soaps and bubble baths. Scrupulous hygiene and liberalfluid intake (unless contraindicated) are excellent preventive measures, but the client also should be
       taught to void every 2 to 3 hours during the day.
       CN: Reduction of risk potential; CL: Analyze

Question 69

69. To prevent recurrence of cystitis, the nurse should plan to encourage the female client to
    include which of the following measures in her daily routine?
70. Wearing cotton underpants.
71. Increasing citrus juice intake.
72. Douching regularly with 0.25% acetic acid.
73. Using vaginal sprays.

Answer 69

69. 1. A woman can adopt several health-promotion measures to prevent the recurrence of
       cystitis, including avoiding too-tight pants, noncotton underpants, and irritating substances, such as
       bubble baths and vaginal soaps and sprays. Increasing citrus juice intake can be a bladder irritant.
       Regular douching is not recommended; it can alter the pH of the vagina, increasing the risk of
       infection.
       CN: Health promotion and maintenance; CL: Synthesize

Question 70

70. The nurse explains to the client the importance of drinking large quantities of fluid to prevent
    cystitis. The nurse should tell the client to drink:
71. Twice as much fluid as usual.
72. At least 1 quart (950 mL) more than usual.
73. A lot of water, juice, and other fluids throughout the day.
74. At least 3,000 mL of fluids daily.

Answer 70

70. 4. Instructions should be as specific as possible, and the nurse should avoid general
       statements such as “a lot.” A specific goal is most useful. A mix of fluids will increase the likelihood
       of client compliance. It may not be sufficient to tell the client to drink twice as much as or 1 quart
       (950 mL) more than she usually drinks if her intake was inadequate to begin with.
       CN: Basic care and comfort; CL: Apply

Question 71

The Client with Pyelonephritis
71. A client is diagnosed with acute pyelonephritis. Which of the following instructions should
the nurse provide to the client about managing the disease?
1. “Urinate frequently because the bacteria that cause acute pyelonephritis reach the kidneys by
means of an infection that progresses upward from lower in the urinary tract.”
2. “Taking frequent bubble baths will decrease the likelihood of further episodes of
pyelonephritis.”
3. “You should take antibiotics for the rest of your life to prevent urinary tract infections.”
4. “By decreasing your fluid intake, you will decrease the need for frequent urination and the
irritating effect of urine in your ureter.”

Answer 71

The Client with Pyelonephritis
71. 1. Pyelonephritis usually begins with colonization and infection of the lower urinary tract via
the ascending urethral route, and the client should have an adequate intake of fluids to promote the
flushing action of urination. Bubble baths and limiting fluid intake increase the risk of developing a
urinary tract infection. Antibiotics should be used on a short-term basis because the risk of antibiotic
resistance may lead to breakthrough infections with increasingly virulent pathogens.
CN: Health promotion and maintenance; CL: Synthesize

Question 72

72. Which of the following symptoms would most likely indicate that the client has
    pyelonephritis?
73. Ascites.
74. Costovertebral angle (CVA) tenderness.
75. Polyuria.
76. Nausea and vomiting.

Answer 72

72. 2. Common symptoms of pyelonephritis include CVA tenderness, burning on urination, urinary
       urgency or frequency, chills, fever, and fatigue. Ascites, polyuria, and nausea and vomiting are not
       indicative of pyelonephritis.
       CN: Physiological adaptation; CL: Analyze

Question 73

73. Which of the following factors would put the client at increased risk for pyelonephritis?
74. History of hypertension.
75. Intake of large quantities of cranberry juice.
76. Fluid intake of 2,000 mL/day.
77. History of diabetes mellitus.

Answer 73

73. 4. A client with a history of diabetes mellitus, urinary tract infections, or renal calculi is at
       increased risk for pyelonephritis. Others at high risk include pregnant women and people with
       structural alterations of the urinary tract. A history of hypertension may put the client at risk for kidney
       damage, but not kidney infection. Intake of large quantities of cranberry juice and a fluid intake of
       2,000 mL/day are not risk factors for pyelonephritis.
       CN: Reduction of risk potential; CL: Analyze

Question 74

74. To assess the client's rental status, the nurse should monitor which of the following laboratory
tests? Select all that apply.
1. Serum sodium
2. Potassium levels.
3. Arterial blood gases.
4. Hemoglobin.
5. Serum blood urea nitrogen (BUN)
6. Creatinine levels.
7. Urinalysis.

Answer 74

74. 5, 6. Serum BUN and creatinine are the tests most commonly used to assess renal function,
    with creatinine being the most reliable indicator. Nonrenal factors may affect BUN levels as well as
    serum sodium and potassium levels. Arterial blood gases and hemoglobin are not used to assess renal
    status. Urinalysis is a general screening test.
    CN: Physiological adaptation; CL: Analyze

Question 75

75. The client with pyelonephritis asks the nurse, “How will I know whether the antibiotics are
    effectively treating my infection?” The nurse’s most appropriate response would be which of the
    following?
76. “After you take the antibiotics for 2 weeks, you’ll not have any infection.”
77. “Your health care provider can tell by the color and odor of your urine.”
78. “Your health care provider will take a urine culture.”
79. “When your symptoms disappear, you’ll know that your infection is gone.”

Answer 75

75. 3. Antibiotics are usually prescribed for a 2- to 4-week period. A urine culture is needed to
       evaluate the effectiveness of antibiotic therapy. Urine must be examined microscopically to
       adequately determine the presence of bacteria; looking at the color of the urine or checking the odor isnot sufficient. Symptoms usually disappear 48 to 72 hours after antibiotic therapy is started, but
       antibiotics may need to continue for up to 4 weeks.
       CN: Pharmacological and parenteral therapies; CL: Evaluate

Question 76

The nurse is to administer 1,200 mg of an antibiotic. The drug is prepared with 6 g of the drug in 2 mL
of solution. The nurse should administer how many milliliters of the drug?
______________________ mL.

Answer 76

76. 0.4 mL

CN: Pharmacologic and parenteral therapy; CL: Apply

Question 77

77. The client with acute pyelonephritis wants to know the possibility of developing chronic
    pyelonephritis. The nurse’s response is based on knowledge of which of the following disorders most
    commonly leads to chronic pyelonephritis?
78. Acute pyelonephritis.
79. Recurrent urinary tract infections.
80. Acute renal failure.
81. Glomerulonephritis.

Answer 77

77. 2. Chronic pyelonephritis is most commonly the result of recurrent urinary tract infections.
       Chronic pyelonephritis can lead to chronic renal failure. Single cases of acute pyelonephritis rarely
       cause chronic pyelonephritis. Acute renal failure is not a cause of chronic pyelonephritis.
       Glomerulonephritis is an immunologic disorder, not an infectious disorder.
       CN: Physiological adaptation; CL: Apply

Question 78

78. A client is diagnosed with pyelonephritis. Which of the following is a priority for care now?
79. Monitor hemoglobin levels.
80. Insert a urinary catheter.
81. Stress importance of use of long-term antibiotics.
82. Ensure sufficient hydration.

Answer 78

78. 4. The nurse should ensure the client has adequate hydration. A urinary catheter is discouraged
       because of the risk of urinary tract infection. Monitoring of the hemoglobin level is not necessary for
       clients with pyelonephritis. Although antibiotics may be prescribed for long-term management and for
       chronic pyelonephritis, at this time the nurse should focus on helping the client maintain hydration.
       CN: Physiologic adaptation; CL: Analyze

Question 79

The Client with Chronic Renal Failure
79. A client with chronic renal failure is receiving hemodialysis three times a week. In order to
protect the fistula the nurse should:
1. Take the blood pressure in the arm with the fistula.
2. Report the loss of a thrill or bruit on the arm with the fistula.
3. Auscultate for a thrill and palpate for a bruit on the arm with the fistula.
4. Start a second IV in the arm with the fistula.

Answer 79

The Client with Chronic Renal Failure
79. 3. The nurse must always palpate for a thrill and auscultate for a bruit in the arm with the
fistula and promptly report the absence of either/or a thrill or bruit to the health care provider as it
indicates an occlusion. No procedures such as IV access, blood pressure measurements, or blood
draws are done on an arm with a fistula as they could damage the fistula.
CN: Physiological adaptation; CL: Synthesize

Question 80

80. A client with chronic renal failure who receives hemodialysis three times a week is
    experiencing severe nausea. What should the nurse advise the client to do to manage the nausea?
    Select all that apply.
81. Drink fluids before eating solid foods.
82. Have limited amounts of fluids only when thirsty.
83. Limit activity.
84. Keep all dialysis appointments.
85. Eat smaller, more frequent meals.

Answer 80

80. 2, 4, 5. To manage nausea, the nurse can advise the client to drink limited amounts of fluid
    only when thirsty, eat food before drinking fluids to alleviate dry mouth, encourage strict follow-up
    for blood work, dialysis, and health care provider visits. Smaller, more frequent meals may help to
    reduce nausea and facilitate medication taking. The client should be as active as possible to avoid
    immobilization because it increases bone demineralization. The client should also maintain the
    dialysis schedule because the dialysis will remove wastes that can contribute to nausea.
    CN: Physiological adaptation; CL: Synthesize

Question 81

81. The dialysis solution is warmed before use in peritoneal dialysis primarily to:
82. Encourage the removal of serum urea.
83. Force potassium back into the cells.
84. Add extra warmth to the body.
85. Promote abdominal muscle relaxation.

Answer 81

81. 1. The main reason for warming the peritoneal dialysis solution is that the warm solution
       helps dilate peritoneal vessels, which increases urea clearance. Warmed dialyzing solution also
       contributes to client comfort by preventing chilly sensations, but this is a secondary reason for
       warming the solution. The warmed solution does not force potassium into the cells or promote
       abdominal muscle relaxation.
       CN: Reduction of risk potential; CL: Apply

Question 82

82. Which of the following assessments would be most appropriate for the nurse to make while
    the dialysis solution is dwelling within the client’s abdomen?
83. Assess for urticaria.
84. Observe respiratory status.
85. Check capillary refill time.
86. Monitor electrolyte status.

Answer 82

82. 2. During dwell time, the dialysis solution is allowed to remain in the peritoneal cavity for the
       time prescribed by the physician (usually 20 to 45 minutes). During this time, the nurse should
       monitor the client’s respiratory status because the pressure of the dialysis solution on the diaphragm
       can create respiratory distress. The dialysis solution would not cause urticaria or affect circulation to
       the fingers. The client’s laboratory values are obtained before beginning treatment and are monitoredevery 4 to 8 hours during the treatment, not just during the dwell time.
       CN: Reduction of risk potential; CL: Analyze

Question 83

83. During the client’s dialysis, the nurse observes that the solution draining from the abdomen is
    consistently blood-tinged. The client has a permanent peritoneal catheter in place. The nurse should
    interpret that the bleeding:
84. Is expected with a permanent peritoneal catheter.
85. Indicates abdominal blood vessel damage.
86. Can indicate kidney damage.
87. Is caused by too-rapid infusion of the dialysate.

Answer 83

83. 2. Because the client has a permanent catheter in place, blood-tinged drainage should not
       occur. Persistent blood-tinged drainage could indicate damage to the abdominal vessels, and the
       physician should be notified. The bleeding is originating in the peritoneal cavity, not the kidneys. Too-
       rapid infusion of the dialysate can cause pain, not blood-tinged drainage.
       CN: Reduction of risk potential; CL: Analyze

Question 84

84. During dialysis, the nurse observes that the flow of dialysate stops before all the solution has
drained out. The nurse should:
1. Have the client sit in a chair.
2. Turn the client from side to side.
3. Reposition the peritoneal catheter.
4. Have the client walk.

Answer 84

84. 2. Fluid return with peritoneal dialysis is accomplished by gravity flow. Actions that enhance
       gravity flow include turning the client from side to side, raising the head of the bed, and gently
       massaging the abdomen. The client is usually confined to a recumbent position during the dialysis.
       The nurse should not attempt to reposition the catheter.
       CN: Reduction of risk potential; CL: Synthesize

Question 85

85. A client undergoing long-term peritoneal dialysis at home is currently experiencing a reducedoutflow from the dialysis catheter. To determine if the catheter is obstructed, the nurse should inquire
whether the client has:
1. Diarrhea.
2. Vomiting.
3. Flatulence.
4. Constipation.

Answer 85

85. 4. Constipation may contribute to reduced urine outflow in part because peristalsis facilitates
       drainage outflow. For this reason, bisacodyl suppositories can be used prophylactically, even without
       a history of constipation. Diarrhea, vomiting, and flatulence typically do not cause decreased outflow
       in a peritoneal dialysis catheter.
       CN: Physiological integrity; CL: Analyze

Question 86

86. Which of the following nursing interventions should be included in the client’s plan of care
    during dialysis therapy?
87. Limit the client’s visitors.
88. Monitor the client’s blood pressure.
89. Pad the side rails of the bed.
90. Keep the client on nothing-by-mouth (NPO) status.

Answer 86

86. 2. Because hypotension is a complication associated with peritoneal dialysis, the nurse
       records intake and output, monitors vital signs, and observes the client’s behavior. The nurse also
       encourages visiting and other diversional activities. A client on peritoneal dialysis does not need to
       be placed in a bed with padded side rails or kept on NPO status.
       CN: Reduction of risk potential; CL: Synthesize

Question 87

87. The client performs self peritoneal dialysis. What should the nurse teach the client about
    preventing peritonitis? Select all that apply.
88. Broad-spectrum antibiotics may be administered to prevent infection.
89. Antibiotics may be added to the dialysate to treat peritonitis.
90. Clean technique is permissible for prevention of peritonitis.
91. Peritonitis is characterized by cloudy dialysate drainage and abdominal discomfort.
92. Peritonitis is the most common and serious complication of peritoneal dialysis.

Answer 87

87. 1, 2, 4, 5. Broad-spectrum antibiotics may be administered to prevent infection when a
    peritoneal catheter is inserted for peritoneal dialysis. If peritonitis is present, antibiotics may be
    added to the dialysate. Aseptic technique is imperative. Peritonitis, the most common and serious
    complication of peritoneal dialysis, is characterized by cloudy dialysate drainage, diffuse abdominal
    pain, and rebound tenderness.
    CN: Safety and infection control; CL: Synthesize

Question 88

88. After completion of peritoneal dialysis, the nurse should assess the client for which of the
following?
1. Hematuria.
2. Weight loss.
3. Hypertension.
4. Increased urine output.

Answer 88

88. 2. Weight loss is expected because of the removal of fluid. The client’s weight before and
       after dialysis is one measure of the effectiveness of treatment. Blood pressure usually decreases
       because of the removal of fluid. Hematuria would not occur after completion of peritoneal dialysis.
       Dialysis only minimally affects the damaged kidneys’ ability to manufacture urine.
       CN: Reduction of risk potential; CL: Evaluate

Question 89

89. Aluminum hydroxide gel (Amphojel) is prescribed for the client with chronic renal failure to
    take at home. What is the expected outcome of giving this drug?
90. Relieving the pain of gastric hyperacidity.
91. Preventing Curling’s stress ulcers.
92. Binding phosphate in the intestine.
93. Reversing metabolic acidosis.

Answer 89

89. 3. A client in renal failure develops hyperphosphatemia that causes a corresponding excretion
       of the body’s calcium stores, leading to renal osteodystrophy. To decrease this loss, aluminum
       hydroxide gel is prescribed to bind phosphates in the intestine and facilitate their excretion. Gastric
       hyperacidity is not necessarily a problem associated with chronic renal failure. Antacids will not
       prevent Curling’s stress ulcers and do not affect metabolic acidosis.
       CN: Pharmacological and parenteral therapies; CL: Evaluate

Question 90

90. The nurse teaches the client with chronic renal failure when to take aluminum hydroxide gel
    (Amphojel). Which of the following statements would indicate that the client understands the
    teaching?
91. “I’ll take it every 4 hours around the clock.”
92. “I’ll take it between meals and at bedtime.”
93. “I’ll take it when I have an upset stomach.”
94. “I’ll take it with meals and bedtime snacks.”

Answer 90

revent Curling’s stress ulcers and do not affect metabolic acidosis.
CN: Pharmacological and parenteral therapies; CL: Evaluate
90. 4. Aluminum hydroxide gel (Amphojel) is administered to bind the phosphates in ingestedfoods and must be given with or immediately after meals and snacks. There is no need for the client to
take it on a 24-hour schedule. It is not administered to treat an upset stomach caused by hyperacidity
in clients with chronic renal failure and therefore is not prescribed between meals.
CN: Pharmacological and parenteral therapies; CL: Evaluate

Question 91

or constipation. The nurse suggests that the client switch to psyllium hydrophilic mucilloid
(Metamucil) because:
1. Milk of magnesia can cause magnesium intoxication.2. Milk of magnesia is too harsh on the bowel.
3. Metamucil is more palatable.
4. Milk of magnesia is high in sodium.

Answer 91

91. 1. Magnesium is normally excreted by the kidneys. When the kidneys fail, magnesium can
       accumulate and cause severe neurologic problems. Milk of magnesia is harsher than Metamucil, but
       magnesium toxicity is a more serious problem. A client may find both milk of magnesia and
       Metamucil unpalatable. Milk of magnesia is not high in sodium.
       CN: Pharmacological and parenteral therapies; CL: Apply

Question 92

92. The nurse is determining which teaching approaches for the client with chronic renal failure
    and uremia would be most appropriate. The nurse should:
93. Provide all needed teaching in one extended session.
94. Validate the client’s understanding of the material frequently.
95. Conduct a one-on-one session with the client.
96. Use videotapes to reinforce the material as needed.

Answer 92

92. 2. Uremia can cause decreased alertness, so the nurse needs to validate the client’s
       comprehension frequently. Because the client’s ability to concentrate is limited, short lessons are most
       effective. If family members are present at the sessions, they can reinforce the material. Written
       materials that the client can review are superior to videotapes because clients may not be able to
       maintain alertness during the viewing of the videotape.
       CN: Physiological adaptation; CL: Synthesize

Question 93

93. The nurse is instructing the client with chronic renal failure to maintain adequate nutritional
    intake. Which of the following diets would be most appropriate?
94. High-carbohydrate, high-protein.
95. High-calcium, high-potassium, high-protein.
96. Low-protein, low-sodium, low-potassium.
97. Low-protein, high-potassium.

Answer 93

93. 3. Dietary management for clients with chronic renal failure is usually designed to restrict
       protein, sodium, and potassium intake. Protein intake is reduced because the kidney can no longer
       excrete the byproducts of protein metabolism. The degree of dietary restriction depends on the degree
       of renal impairment. The client should also receive a high-carbohydrate diet along with appropriate
       vitamin and mineral supplements. Calcium requirements remain 1,000 to 2,000 mg/day.
       CN: Basic care and comfort; CL: Synthesize

Question 94

94. The nurse is discussing concerns about sexual activity with a client with chronic renal
    failure. Which one of the following strategies would be most useful?
95. Help the client to accept that sexual activity will be decreased.
96. Suggest using alternative forms of sexual expression and intimacy.
97. Tell the client to plan rest periods after sexual activity.
98. Suggest that the client avoid sexual activity to prevent embarrassment.

Answer 94

94. 2. Altered sexual functioning commonly occurs in chronic renal failure and can stress
       marriages and relationships. Altered sexual functioning can be caused by decreased hormone levels,
       anemia, peripheral neuropathy, or medication. The client should not decrease or avoid sexual activity
       but instead should modify it. The client should rest before sexual activity.
       CN: Psychosocial integrity; CL: Synthesize

Question 95

95. A client with chronic renal failure has asked to be evaluated for a home continuous
    ambulatory peritoneal dialysis (CAPD) program. The nurse should explain that the major advantage
    of this approach is that it:
96. Is relatively low in cost.
97. Allows the client to be more independent.
98. Is faster and more efficient than standard peritoneal dialysis.
99. Has fewer potential complications than standard peritoneal dialysis.

Answer 95

95. 2. The major benefit of CAPD is that it frees the client from daily dependence on dialysis
       centers, health care personnel, and machines for life-sustaining treatment. This independence is a
       valuable outcome for some people. CAPD is costly and must be done daily. Adverse effects and
       complications are similar to those of standard peritoneal dialysis. Peritoneal dialysis usually takes
       less time but cannot be done at home.
       CN: Reduction of risk potential; CL: Apply

Question 96

96. The client asks about diet changes when using continuous ambulatory peritoneal dialysis
    (CAPD). Which of the following would be the nurse’s best response?
97. “Diet restrictions are more rigid with CAPD because standard peritoneal dialysis is a more
    effective technique.”
98. “Diet restrictions are the same for both CAPD and standard peritoneal dialysis.”
99. “Diet restrictions with CAPD are fewer than with standard peritoneal dialysis because
    dialysis is constant.”
100. “Diet restrictions with CAPD are fewer than with standard peritoneal dialysis because CAPD
     works more quickly.”

Answer 96

96. 3. Dietary restrictions with CAPD are fewer than those with standard peritoneal dialysis
       because dialysis is constant, not intermittent. The constant slow diffusion of CAPD helps prevent
       accumulation of toxins and allows for a more liberal diet. CAPD does not work more quickly, but
       more consistently. Both types of peritoneal dialysis are effective.
       CN: Basic care and comfort; CL: Synthesize

Question 97

97. A client is receiving continuous ambulatory peritoneal dialysis (CAPD). The nurse should
    assess the client for which of the following signs of peritoneal infection?
98. Cloudy dialysate fluid.
99. Swelling in the legs.
100. Poor drainage of the dialysate fluid.4. Redness at the catheter insertion site.

Answer 97

97. 1. Cloudy drainage indicates bacterial activity in the peritoneum. Other signs and symptoms of
       infection are fever, hyperactive bowel sounds, and abdominal pain. Swollen legs may indicate heart
       failure. Poor drainage of dialysate fluid is probably the result of a kinked catheter. Redness at theinsertion site indicates local infection, not peritonitis. However, a local infection that is left untreated
       can progress to the peritoneum.
       CN: Reduction of risk potential; CL: Analyze

Question 98

The Client with Urinary Incontinence
98. What should the nurse teach the client to do to prevent stress incontinence? Select all that
apply.
1. Use techniques that strengthen the sphincter and structural supports of the bladder, such as
Kegel exercises.
2. Avoid dietary irritants (eg, caffeine, alcoholic beverages).
3. Not to laugh when in social gatherings.
4. Carry an extra incontinence pad when away from home.
5. Obtain a fluid intake of 500 mL/day.

Answer 98

The Client with Urinary Incontinence
98. 1, 2. Laughing may be a part of one’s socialization, so it should not be discouraged. In non-
restricted clients, a fluid intake of at least 2 to 3 L/day is encouraged; clients with stress incontinence
may reduce their fluid intake to avoid incontinence at the risk of developing dehydration and urinary
tract infections. Establishing a voiding schedule would be more effective in the prevention of stress
incontinence rather than carrying incontinence pads. Dietary irritants and natural diuretics, such as
caffeine and alcoholic beverages, may increase stress incontinence. Kegel exercises strengthen the
sphincter and structural supports of the bladder.
CN: Health promotion and maintenance; CL: Synthesize

Question 99

99. A client has stress incontinence. Which of the following data from the client’s history
    contributes to the client’s incontinence?
100. The client’s intake of 2 to 3 L of fluid per day.
101. The client’s history of three full-term pregnancies.
102. The client’s age of 45 years.
103. The client’s history of competitive swimming.

Answer 99

99. 2. The history of three pregnancies is most likely the cause of the client’s current episodes of
       stress incontinence. The client’s fluid intake, age, or history of swimming would not create an
       increase in intra-abdominal pressure.
       CN: Reduction of risk potential; CL: Analyze

Question 100

100. The primary goal of nursing care for a client with stress incontinence is to:
101. Help the client adjust to the frequent episodes of incontinence.
102. Eliminate all episodes of incontinence.
103. Prevent the development of urinary tract infections.
104. Decrease the number of incontinence episodes.

Answer 100

100. 4. The primary goal of nursing care is to decrease the number of incontinence episodes and
        the amount of urine expressed in an episode. Behavioral interventions (eg, diet and exercise) and
        medications are the nonsurgical management methods used to treat stress incontinence. Without
        surgical intervention, it may not be possible to eliminate all episodes of incontinence. Helping the
        client adjust to the incontinence is not treating the problem. Clients with stress incontinence are not
        prone to the development of urinary tract infection.
        CN: Physiological adaptation; CL: Synthesize

Question 101

101. The nurse is developing a teaching plan for a client with stress incontinence. Which of the
     following instructions should be included?
102. Avoid activities that are stressful and upsetting.
103. Avoid caffeine and alcohol.
104. Do not wear a girdle.
105. Limit physical exertion.

Answer 101

101. 2. Clients with stress incontinence are encouraged to avoid substances, such as caffeine and
        alcohol, that are bladder irritants. Emotional stressors do not cause stress incontinence. It is most
        commonly caused by relaxed pelvic musculature. Wearing girdles is not contraindicated. Although
        clients may want to limit physical exertion to avoid incontinence episodes, they should be encouraged
        to seek treatment instead of limiting their activities.
        CN: Reduction of risk potential; CL: Create

Question 102

102. A client has urge incontinence. When obtaining the health history, the nurse should ask if the
     client has:
103. Inability to empty the bladder.
104. Loss of urine when coughing.
105. Involuntary urination with minimal warning.
106. Frequent dribbling of urine.

Answer 102

102. 3. A characteristic of urge incontinence is involuntary urination with little or no warning.
        The inability to empty the bladder is urine retention. Loss of urine when coughing occurs with stress
        incontinence. Frequent dribbling of urine is common in male clients after some types of prostate
        surgery or may occur in women after the development of a vesicovaginal or urethrovaginal fistula.
        CN: Physiological adaptation; CL: Analyze

Question 103

103. Which of the following interventions would be most appropriate for a client who has urge
     incontinence?
104. Have the client urinate on a timed schedule.
105. Provide a bedside commode.
106. Administer prophylactic antibiotics.
107. Teach the client intermittent self-catheterization technique

Answer 103

103. 1. Instructing the client to void at regularly scheduled intervals can help decrease the
        frequency of incontinence episodes. Providing a bedside commode does not decrease the number of
        incontinence episodes and does not help the client who leads an active lifestyle. Infections are not a
        common cause of urge incontinence, so antibiotics are not an appropriate treatment. Intermittent self-
        catheterization is appropriate for overflow or reflux incontinence, but not urge incontinence, because
        it does not treat the underlying cause.CN: Physiological adaptation; CL: Synthesize

Question 104

Managing Care Quality and Safety
104. A client is scheduled for an intravenous pyelogram (IVP). The evening before the
procedure, the nurse learns that the client has a sensitivity to shellfish. The nurse should:
1. Administer a cathartic to the client to empty the colon.
2. Administer an antiflatulent to the client to relieve gas.
3. Keep the client on nothing-by-mouth (NPO) status.
4. Cancel the IVP and notify the physician.

Answer 104

Managing Care Quality and Safety
104. 4. Sensitivity to shellfish or iodine may cause an anaphylactic reaction to the contrast
material, which contains iodine. Administering a cathartic or antiflatulent will not prevent an
anaphylactic reaction to the contrast material. Keeping a client on NPO status for 8 hours before the
procedure is part of the usual preparation for such a procedure to prevent aspiration of food or fluids
if the client vomits when lying on the x-ray table.
CN: Reduction of risk potential; CL: Synthesize

Question 105

105. The nurse finds a container with the client’s urine specimen sitting on a counter in the
     bathroom. The client states that the specimen has been sitting in the bathroom for at least 2 hours. The
     nurse should:
106. Discard the urine and obtain a new specimen.
107. Send the urine to the laboratory as quickly as possible.
108. Add fresh urine to the collected specimen and send the specimen to the laboratory.
109. Refrigerate the specimen until it can be transported to the laboratory.

Answer 105

105. 1. The appropriate action would be to discard the specimen and obtain a new one. Urine that
        is allowed to stand at room temperature will become alkaline, with multiplying bacteria. The
        specimen should be examined within 1 hour after urination.
        CN: Reduction of risk potential; CL: Synthesize

Question 106

106. A client with early acute renal failure has anemia, tachycardia, hypotension, and shortness
     of breath. The physician has prescribed 2 units of packed red blood cells (RBCs). Prior to initiating
     the blood transfusion the nurse should determine if: (Select all that apply.)
107. There is an IV access with the appropriate tubing and normal saline as the priming solution.
108. There is a signed informed consent for transfusion therapy.
109. Blood typing and cross-matching are documented in the medical record.
110. The vital signs have been taken and documented in accordance with facility policy and
     procedure.
111. There is the second unit of blood in the medication room.
112. The client has an identification bracelet and red blood band.

Answer 106

106. 1, 2, 3, 4, 6. Before prescribing and administering packed RBCs, the nurse should assess the
     IV site to make sure it has an 18G to 20G Angiocath. The nurse should also ensure that normal saline
     solution is used to prime the tubing to prevent RBCs from adhering to the tubing. The client must
     indicate informed consent for the procedure by signing the consent form. The client’s blood must be
     typed to determine ABO blood typing and Rh factor and ensure that the client receives compatible
     blood. Cross-matching is done to detect the presence of recipient antibodies to the donor’s minor
     antigens. Vital signs provide a baseline reference for continuous monitoring throughout the
     transfusion. An identification bracelet and red blood band are essential for client identification per
     facility policy. Two nurses must double check the client’s identification with the client listed on the
     unit of RBCs. The transfusion should be started within 30 minutes of the time that the RBC unit is
     checked out of the blood bank. Thus, no blood should be kept in the medication room before
     transfusion.
     CN: Safety and infection control; CL: Synthesize

Question 107

107. The nurse is instructing the unlicensed nursing personnel (UAP) about the correct technique
     for obtaining a clean-catch urine culture from a female client. Which of the following statements
     indicates that the assistant has understood the instructions?
108. “I will have the client completely empty her bladder into the specimen cup.”
109. “I will need to catheterize the client to get the urine specimen.”
110. “I will ask the client to clean her labia, void into the toilet, and then into the specimen cup.”
111. “I will obtain the specimen in the afternoon after the client has had plenty of fluids.”

Answer 107

107. 3. The correct technique for a clean-catch urine culture specimen is to have the female client
        clean the labia from front to back, void into the toilet, and then void into the cup. The client does not
        need to fully empty her bladder into the cup. It is not necessary to catheterize the client to obtain the
        specimen. The first voided specimen of the day has the highest bacterial counts.
        CN: Basic care and comfort; CL: Evaluate

Question 108

108. An elderly client admitted with new-onset confusion, headache, poor skin turgor, bounding
     pulse and urinary incontinence has been drinking copious amounts of water. Upon reviewing the lab
     results, the nurse discovers a sodium level of 122 mEq/L (122 mmol/L). A report to the physician
     should include what recommendations? Select all that apply.
109. Fluid restriction.
110. Encourage fluids.
111. Vital signs every 4 hours instead of every shift.
112. Bed alarm.
113. Foley catheter.
114. Strict intake and output.7. Repeat electrolytes, urine for sodium and specific gravity in the morning.
115. 2 g sodium diet.

Answer 108

108. 1, 3, 4, 5, 6, 7. The client is hyponatremic; the nurse will closely monitor vital signs, restrict
     fluids, accurately record intake and output with the aid of a Foley catheter, prescribe labs for morning
     and ensure patient safety with use of bed alarm. Encouraging fluids and restricting dietary sodium to 2
     g may further exacerbate the hyponatremia. The nurse will also monitor for neurological changes and
     inform the physician immediately of any change or if the client becomes unable to take food/fluids by
     mouth.
     CN: Management of care; CL: Synthesize

Question 109

109. Which of the responsibilities related to the care of a client with a Foley catheter are
     appropriate for the nurse to delegate to the nursing assistant? Select all that apply.
110. Flush the catheter as needed to ensure patency.
111. Empty drainage bag and record output at specified times.
112. Apply catheter-securing device to client’s leg.
113. Perform bladder irrigation as prescribed.
114. Provide Foley catheter and perineal care each shift.
115. Ensure the urine drainage bag is below the level of the bladder at all times.

Answer 109

109. 2, 3, 5, 6. While the scope of practice for nurse assistants may vary by state, province, or
     territory, as well as by place of employment, general duties include recording input and output,
     including emptying and recording urine output from a Foley catheter. A nurse assistant with propertraining may apply a securing device to maintain safety, provide regular Foley catheter and perineal
     care and ambulate a client with a catheter, continually monitoring that the collection bag remains
     below the level of the bladder to help prevent infection. Activities such as irrigating or flushing a
     catheter should not be assigned to a nursing assistant as these activities involve nursing assessment
     skills.
     CN: Management of care; CL: Evaluate

Question 110

110. The client is to receive antibiotic intravenous (IV) therapy in the home. The nurse should
     develop a teaching plan to ensure that the client and family can manage the IV fluid and infusion
     correctly and avoid complications. The plan should include which of the following? Select all that
     apply.
111. Report signs of redness or inflammation at the site.
112. Wear sterile gloves to change the fluids.
113. Call the health care provider for a temperature above 100°F (37.8°C).
114. Cleanse the port with alcohol wipes.
115. Place the IV bag on a table level with the client’s arm.

Answer 110

110. 1, 3, 4. When intravenous (IV) therapy must be administered in the home setting, teaching is
     essential. Written instructions, as well as demonstration and return demonstration help reinforce key
     points. The client and/or caregiver is responsible for adhering to the established plan of care that
     includes the treatment plan, monitoring plan, potential for complications, expected outcome/s,
     potential adverse effects, and plan for communicating with the health care provider. Periodic
     laboratory testing may be necessary to assess the effects of IV therapy and the client’s progress. The
     client should report signs of redness or inflammation that could indicate infection, and also report an
     elevated temperature. Prior to changing the fluids, the caregiver should cleanse the port with alcohol
     wipes. It is not necessary to use sterile gloves; the IV bag should be elevated to promote gravity flow.
     CN: Reduction of risk potential; CL: Create

Question 111

111. Prior to discharging a client with cancer of the bladder from the hospital, the nurse must do
     which of the following? Select all that apply.
112. Determine if the client is likely to become suicidal.
113. Give a list of the client’s medications to the client before discharge.
114. Instruct the client to update information when medications are discontinued, doses are changed,
     or new medications are added.
115. Explain the need to carry medication information with the client at all times.
116. Instruct the client that the use of over-the-counter products need not be reported to the health
     care provider.

Answer 111

111. 1, 2, 3, 4. To ensure client safety, assess which clients are most likely to try to commit
     suicide, and maintain and communicate accurate client medication information, the nurse should
     explain the importance of managing medication information to the client when he/she is discharged
     from the hospital or at the end of an outpatient encounter. Examples include: instructing the client to
     give a list to his/her primary care physician; to update the information when medications are
     discontinued, doses are changed, or new medications including over-the-counter products are added;
     and to carry medication information at all times in the event of emergency situations.
     CN: Safety and infection control; CL: Application