Chapter 39 My Nursing Test Banks

Osborn, Medical-Surgical Nursing, 2e
Chapter 39

Question 1

Type: MCSA

A female patient asks the nurse about ways to prevent recurrent cystitis. What is an appropriate nursing response?

1. Void before and as soon as possible after sexual intercourse.

2. Clean the perineal area from back to front.

3. Soak in a bathtub at least once a week.

4. Wear clean, nylon underpants.

Correct Answer: 1

Rationale 1: Voiding before and as soon as possible after sexual intercourse flushes contaminants that may have entered the urethra.

Rationale 2: Women should be instructed to cleanse the perineal area from front to back after voiding and defecating.

Rationale 3: The patient should avoid tub baths.

Rationale 4: Measures to maintain the integrity of perineal tissues include wearing cotton briefs.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 39-3

Question 2

Type: MCSA

A male patient comes to the emergency department with symptoms of renal colic. The nurse realizes that this patient most likely has a calculus that is obstructing which structure?

1. Ureter

2. Bladder

3. Renal pelvis

4. Urethra

Correct Answer: 1

Rationale 1: Renal colic is acute, severe flank pain on the affected side. It develops when a stone, or renal calculus, obstructs the ureter and causes ureteral spasm.

Rationale 2: A calculus in the bladder would not cause renal colic.

Rationale 3: A calculus in the renal pelvis would cause chronic dull pain rather than colicky pain.

Rationale 4: A calculus in the urethra would not cause renal colic.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 39-3

Question 3

Type: MCSA

A male patient is admitted for removal of a bladder papilloma. Which assessment finding would the nurse evaluate as having increased the patients risk of this disorder?

1. History of cigarette smoking

2. Low daily fluid intake

3. Weak pedal pulses

4. Decreased appetite level

Correct Answer: 1

Rationale 1: Approximately 50% of those diagnosed with bladder cancer are smokers.

Rationale 2: Daily fluid intake is an important assessment, but this finding would not indicate an increased risk for bladder papilloma.

Rationale 3: Pedal pulses are an important assessment, but this finding would not indicate an increased risk for bladder papilloma.

Rationale 4: Appetite is an important assessment, but this finding would not indicate an increased risk for bladder papilloma.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 39-3

Question 4

Type: MCSA

A patient had a renal stent removed. Which intervention is the priority of care for this patient?

1. Monitor urine output.

2. Encourage ambulation.

3. Ensure an adequate protein intake.

4. Monitor blood pressure.

Correct Answer: 1

Rationale 1: Urine output is closely monitored for the first 24 hours after stents or ureteral catheters are removed. Edema or stricture of ureters may impede output and lead to hydronephrosis and kidney damage.

Rationale 2: Ambulation is important in the care of this patient; however, it is not the highest priority.

Rationale 3: Adequate protein intake is important in the care of this patient; however, it is not the highest priority.

Rationale 4: Blood pressure monitoring is important in the care of this patient; however, it is not the highest priority.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 39-3

Question 5

Type: MCSA

A male patient with a urinary stoma says, I looked at it while you were out of the room. Its not so bad. How should the nurse evaluate this statement?

1. The patient is making progress with coping.

2. The patient is in denial.

3. The patient has not grieved for his body image.

4. The patient is angry.

Correct Answer: 1

Rationale 1: Accepting the stoma as part of the self is vital to adapting to the changed body image.

Rationale 2: The patient may initially use defensive coping mechanisms such as denial, minimization, and dissociation to reduce anxiety and maintain psychological integrity. This patient is in a stage of acceptance rather than denial.

Rationale 3: This statement does not indicate a lack of grieving.

Rationale 4: This statement does not indicate anger.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 39-3

Question 6

Type: MCSA

A female patient is admitted with an overdistended bladder. Which diagnostic test can be done to confirm the diagnosis of urine retention?

1. Bladder scan

2. Renal scan

3. Intravenous pyelography (IVP)

4. MRI

Correct Answer: 1

Rationale 1: Urinary retention is confirmed using a bladder scan or by inserting a urinary catheter (if possible) and measuring the urine output.

Rationale 2: A renal scan provides information about the structure of the kidney and vascular flow in the renal system, but it is not the test of choice in determining urine retention.

Rationale 3: Intravenous pyelography (IVP) provides information about the structure of the kidney and vascular flow in the renal system, but it is not the test of choice in determining urine retention.

Rationale 4: MRI provides information about the structure of the kidney and vascular flow in the renal system, but it is not the test of choice in determining urine retention.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 39-2

Question 7

Type: MCSA

An 80-year-old female patient says to the nurse, I cant hold my water very well so I dont leave the house much. Which nursing response is appropriate?

1. There may be some ways to help you hold your water better.

2. I understand.

3. I guess its hard getting older.

4. I wish there was something we could do to help you.

Correct Answer: 1

Rationale 1: Although urinary incontinence rarely causes serious physical effects, it can have significant psychosocial effects such as lowered self-esteem, social isolation, and even institutionalization. Urinary incontinence is not a normal consequence of aging; treatments are available.

Rationale 2: The nurse must give a response that addresses the problem while being empathetic.

Rationale 3: The nurse must give a response that addresses the problem while being empathetic.

Rationale 4: There are treatments for urinary incontinence that can be suggested for this patient or discussed with the primary care provider.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 39-3

Question 8

Type: MCMA

A patient with a history of renal calculi has been instructed to acidify his urine. The nurse would suggest intake of which foods or fluids?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Orange juice

2. Cranberries

3. Chocolate

4. Dairy products

5. Water

Correct Answer: 1,2

Rationale 1: Fruit juices will acidify the urine.

Rationale 2: Cranberries will acidify the urine.

Rationale 3: Chocolate will not acidify the urine.

Rationale 4: Dairy products are a source of calcium but will not acidify the urine.

Rationale 5: Water will flush the urinary tract but will not acidify the urine.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 39-3

Question 9

Type: MCSA

A patient who is recovering from spinal surgery had an accident while attempting to reach the bathroom to void. Which type of incontinence is this patient most likely experiencing?

1. Functional

2. Urge

3. Stress

4. Overflow

Correct Answer: 1

Rationale 1: Functional incontinence results from physical, environmental, or psychosocial causes. Impaired mobility is one such cause.

Rationale 2: Urge incontinence occurs when the patient must void immediately when the urge is perceived.

Rationale 3: Stress incontinence is the result of coughing or laughing.

Rationale 4: Overflow incontinence occurs when the bladder becomes too full to hold the urine. Often, the patient feels little need to void.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 39-3

Question 10

Type: MCMA

A patient is participating in bladder retraining activities. Which toileting activities can reduce episodes of incontinence?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Scheduled toileting

2. Kegel exercises

3. Intermittent straight catheterization

4. External catheter placement at bedtime

5. Use of adult incontinence protection devices

Correct Answer: 1,2

Rationale 1: Scheduled toileting is toileting at regular intervals (e.g., every 2 to 4 hours).

Rationale 2: Kegel exercises may help female patients become more reliably continent.

Rationale 3: Intermittent straight catheterization is not a toileting activity.

Rationale 4: Placement of external catheter devices does not reduce periods of incontinence.

Rationale 5: Use of adult incontinence devices does not reduce periods of incontinence.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 39-3

Question 11

Type: MCMA

A patient is being instructed on how to perform Kegel exercises. What should be included in these instructions?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. While voiding, stop the flow of urine and hold for a few minutes.

2. Tighten the identified muscles for 2 to 3 seconds.

3. Take a deep breath and hold while performing the exercise.

4. Tighten the stomach muscles while performing Kegel exercises.

5. Improvement may take several weeks.

Correct Answer: 1,2,5

Rationale 1: Trying to stop the flow of urine helps the patient identify the correct muscles.

Rationale 2: The patient should be taught to tighten and hold the identified muscles for 2 to 3 seconds.

Rationale 3: The patient should keep breathing relaxed while performing Kegel exercises.

Rationale 4: The stomach, buttock, and thigh muscles should not be tightened.

Rationale 5: Improvement may not be seen for 3 to 6 weeks.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 39-3

Question 12

Type: MCSA

Which age-related change contributes to the increased incidence of urinary tract infections (UTIs) among older adult females?

1. Thinning of vaginal mucosa

2. Enhanced immune response

3. Reduced risk of urinary stasis

4. Reduced focus on personal cleanliness

Correct Answer: 1

Rationale 1: The thinning of vaginal mucosa disrupts healthy vagina flora, resulting in bacteriuria.

Rationale 2: A diminished immune response contributes to the increased incidence of UTIs in older females.

Rationale 3: An increased risk of urinary stasis contributes to the higher incidence of UTIs in older females.

Rationale 4: There is no indication that a reduced focus on personal cleanliness is a normal part of aging.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 39-3

Question 13

Type: MCSA

A patient diagnosed with a symptomatic urinary tract infection (UTI) is prescribed phenazopyridine (Pyridium). Which medication education should the nurse provide?

1. This medication will make your urine orange or red.

2. This medication will kill the bacteria in your urine.

3. Take this medication until the prescription is finished.

4. Dont worry if your skin turns a yellowish color.

Correct Answer: 1

Rationale 1: Phenazopyridine (Pyridium) turns urine orange or red.

Rationale 2: Phenazopyridine is a urinary analgesic, not an antibiotic.

Rationale 3: Phenazopyridine is a urinary analgesic that should be taken only as long as needed.

Rationale 4: The patient should immediately contact the prescriber if the skin or sclera appears to be yellow.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 39-3

Question 14

Type: MCSA

Which statement by a patient with uric acid stones indicates that the nurses instruction about ways to prevent lithiasis was effective?

1. I should avoid organ meats and sardines in my diet.

2. I will increase purine-rich foods in my diet.

3. The goal is to drink enough water that my urine is yellow.

4. I will have to make my urine more acidic by eating cheese, cranberries, grapes, and tomatoes.

Correct Answer: 1

Rationale 1: The patient with uric acid stones requires a diet low in purines, which are found in organ meats and sardines.

Rationale 2: The patient with uric acid stones requires a diet low in purines.

Rationale 3: The goal is to drink enough water that the urine is colorless.

Rationale 4: Acidifying the urine reduces the formation of calcium phosphate and magnesium ammonium phosphate calculi rather than uric acid calculi.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 39-3

Question 15

Type: MCSA

The nurse is giving discharge instructions to a patient diagnosed with pyelonephritis. Which statement by the patient would indicate that learning has occurred?

1. Pyelonephritis is an infection of the kidney.

2. Pyelonephritis is an inflammation of the bladder.

3. Pyelonephritis is an infection of the lower urinary tract.

4. Pyelonephritis is a blockage in the tube from the kidney to the bladder.

Correct Answer: 1

Rationale 1: Pyelonephritis is an infection of the renal pelvis and parenchyma, the functional unit of the kidney.

Rationale 2: Pyelonephritis is not an inflammation of the bladder.

Rationale 3: Pyelonephritis does not occur in the lower urinary tract or ureter.

Rationale 4: Pyelonephritis does not occur in the lower urinary tract or ureter.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 39-3

Question 16

Type: MCSA

The nurse reviews a patients data and recognizes the symptoms as being compatible with which diagnosis?

1. Pyelonephritis

2. Nephrolithiasis

3. Hydronephrosis

4. Cystitis

Correct Answer: 1

Rationale 1: Pyelonephritis usually has a rapid onset, with chills and fever, malaise, vomiting, flank pain, costovertebral tenderness, diarrhea, hematuria, pyuria, and urinary frequency. Laboratory diagnosis indicates a high bacteria count, and urine is cloudy and more alkaline. E. coli is present in 85% of cases.

Rationale 2: Nephrolithiasis may have few symptoms until a stone blocks urine flow; a dull flank pain may be present.

Rationale 3: Patients with hydronephrosis typically have colicky pain on the affected side that may radiate to the groin; otherwise, manifestations are few.

Rationale 4: Cystitis presents with symptoms of dysuria, urinary frequency, and urgency, and urine may have a foul odor and a cloudy or bloody appearance. But symptoms are more localized to the suprapubic and lower pelvic regions.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 39-3

Question 17

Type: MCSA

A patient has been admitted with a possible kidney stone. The nurse would expect the patients pain to radiate from which area?

1. The middle of the back, between the scapulas

2. Very low in the center of the back

3. The area where the ribs and spine come together

4. The middle of the abdomen, just above the umbilicus

5.

Correct Answer: 3

Rationale 1: Pain from kidney stones does not radiate from between the scapulas.

Rationale 2: Pain from kidney stones does not radiate from the low back.

Rationale 3: This area is the costovertebral angle and is the area from which kidney stone pain often radiates.

Rationale 4: Kidney stone pain is not located in the front of the abdomen.

Rationale 5:

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 39-3

Question 18

Type: MCSA

The nurse would contact the health care provider with concerns that this patient is demonstrating which complication of urinary calculi?

1. Hydronephrosis

2. Infection

3. Renal colic

4. Ureteral tumor

Correct Answer: 1

Rationale 1: Hydronephrosis is swelling of the kidney caused by retention of urine, usually because of an obstruction or blockage. It typically manifests with colicky pain on the affected side that may radiate to the groin. When significant, a palpable mass may be felt in the flank region. Hematuria and signs of a urinary tract infection (UTI) such as fever and pyuria may occur. Other symptoms include nausea and vomiting.

Rationale 2: Infection would not result in a palpable mass in the LUQ.

Rationale 3: Renal colic is the term for the pain associated with ureteral spasm caused by a stone obstructing the ureter.

Rationale 4: Ureteral tumors manifest as painless hematuria; they may cause colicky pain from obstruction but typically have few outward signs until urine flow is obstructed.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 39-5

Question 19

Type: MCSA

An elderly patient is admitted to the hospital with cardiac complications associated with diabetes. What should be of concern to the nurse regarding this patients medications?

1. The type and amount of medications in relation to the patients renal function

2. Whether the patient is taking the prescribed dosages

3. Which vitamins and supplements the patient is taking

4. The cost of the patients medications

Correct Answer: 1

Rationale 1: A decreased glomerular filtration rate (GFR) in the older adult reduces the clearance of drugs excreted through the kidneys, prolonging the half-life of drugs and possibly requiring lower drug doses and longer dosing intervals. Common medications affected by decreased GFR include cardiac medications and antidiabetic agents.

Rationale 2: Assessing the patients compliance with prescribed doses is important in any circumstance but is not specific to this scenario.

Rationale 3: Use of vitamin supplements should be assessed, but it is not specific to the situation described.

Rationale 4: The nurse might suspect noncompliance if the cost of medications is an issue. This concern would not be specific to this scenario, however.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 39-1

Question 20

Type: MCSA

A patient is diagnosed with hypertension caused by polycystic kidney disease. Which intervention might be helpful to control this patients blood pressure and slow the progression of renal failure?

1. Administration of ACE inhibitors

2. Kidney transplant

3. Hemodialysis

4. Peritoneal dialysis

Correct Answer: 1

Rationale 1: Hypertension associated with polycystic disease is generally controlled using angiotensin-converting enzyme (ACE) inhibitors or other antihypertensive agents.

Rationale 2: Renal transplant is indicated when kidney function cannot control the wastes from metabolic processes.

Rationale 3: Dialysis is indicated when kidney function cannot control the wastes from metabolic processes.

Rationale 4: Dialysis is indicated when kidney function cannot control the wastes from metabolic processes.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 39-5

Question 21

Type: MCSA

Three weeks after being treated for strep throat, a patient comes into the clinic with signs of acute glomerulonephritis. Which symptom will the nurse most likely find upon assessment of this patient?

1. Periorbital edema

2. Hunger

3. Polyuria

4. Anuria

Correct Answer: 1

Rationale 1: Salt and water retention increase extracellular fluid volume, which leads to hypertension and edema. The edema is primarily noted in the face, particularly around the eyes (periorbital edema).

Rationale 2: Hunger (polyphagia) is not a symptom typically associated with glomerulonephritis.

Rationale 3: Polyuria is not a symptom typically associated with glomerulonephritis.

Rationale 4: Oliguria, not anuria, is generally a presenting sign of glomerulonephritis.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 39-3

Question 22

Type: MCSA

The nurse is planning the care of a patient with chronic glomerulonephritis. What should be the goal of treatment for this patient?

1. Maintaining renal function

2. Achieving maximum independence

3. Returning to work as soon as possible

4. Successful lifestyle adaptation

Correct Answer: 1

Rationale 1: Management of all types of glomerulonephritis focuses on identifying the underlying disease process and preserving kidney function. Treatment goals are to maintain renal function, prevent complications, and support the healing process.

Rationale 2: Although maintenance of independence may be included in the plan of care, it is not a priority.

Rationale 3: Although returning to work may be included in the plan of care, it is not a priority.

Rationale 4: Although lifestyle adaptation may be included in the plan of care, it is not a priority.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 39-3

Question 23

Type: MCSA

Which intervention would be appropriate for a patient with Fluid Volume Excess related to chronic glomerulonephritis?

1. Weigh daily on the same scale.

2. Document energy level.

3. Schedule activities to conserve energy.

4. Assess for signs of infection.

Correct Answer: 1

Rationale 1: The patient should be weighed daily using a consistent technique (i.e., time of day, scale, and clothing).

Rationale 2: Energy level does not address the issue of Fluid Volume Excess.

Rationale 3: Energy level does not address the issue of Fluid Volume Excess.

Rationale 4: Signs of infection do not address the issue of Fluid Volume Excess.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 39-4

Question 24

Type: MCSA

A patient with chronic kidney disease is diagnosed with hypertension. The nurse understands that this patients blood pressure needs to be controlled for which reason?

1. Treating hypertension can slow the decline of kidney function.

2. Hypertension must be controlled for any other treatment for kidney disease to be effective.

3. The medications used to treat hypertension also reverse physical changes associated with chronic kidney failure.

4. Everyone should have low-normal blood pressure.

Correct Answer: 1

Rationale 1: Management of hypertension to maintain blood pressure within normal limits prevents kidney damage. When hypertension is secondary to kidney disease, adequate blood pressure control can slow the decline of renal function.

Rationale 2: Control of hypertension is one part of the treatment for kidney disease. It is not essential to have hypertension controlled for other treatments to be effective.

Rationale 3: It is not true that medications for hypertension reverse kidney damage and failure.

Rationale 4: This concept does not apply to this patient because of the new diagnosis and the history of chronic kidney disease.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 39-4

Question 25

Type: MCMA

A patient is scheduled to have an arteriovenous (AV) fistula created for hemodialysis. Which education should the nurse provide regarding this fistula?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. The opposite arm should be used for blood pressure readings.

2. A functioning fistula has a palpable pulse and bruit.

3. The health care provider should be contacted if the hand is cool and painful.

4. The fistula can be used immediately after its creation.

5. Venipunctures should be performed on the arm with the fistula.

Correct Answer: 1,2

Rationale 1: The arm in which a fistula is placed should not be used for blood pressure, and that arm should be marked as not available for this purpose.

Rationale 2: A functional AV fistula has a palpable pulse and a bruit on auscultation.

Rationale 3: Arterial insufficiency may result from arterial steal syndrome.

Rationale 4: It takes about a month for the fistula to mature.

Rationale 5: The arm in which a fistula is placed should not be used for venipuncture, and that arm should be marked as not available for this purpose.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 39-6

Question 26

Type: MCSA

A patient is admitted with signs of chronic renal failure. Which finding would alert the nurse to possible metabolic acidosis?

1. Kussmauls respirations

2. Low urine output

3. Muscle cramps

4. Diarrhea

Correct Answer: 1

Rationale 1: As renal failure progresses, hydrogen-ion excretion and buffer production are impaired, leading to metabolic acidosis. Respiratory rate and depth increase, as with Kussmauls respirations, to compensate.

Rationale 2: Low urine output is often associated with chronic renal failure, but another finding would be the clearest indication of metabolic acidosis.

Rationale 3: Muscle cramps are often associated with chronic renal failure, but another finding would be the clearest indication of metabolic acidosis.

Rationale 4: Diarrhea is often associated with chronic renal failure, but another finding would be the clearest indication of metabolic acidosis.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 39-4

Question 27

Type: MCSA

A patient who received a kidney transplant 7 years ago is seen for increasing blood pressure and proteinuria. The nurse conducts additional assessment for which complication?

1. Chronic kidney rejection

2. Acute kidney rejection

3. Renal artery stenosis

4. Pyelonephritis

Correct Answer: 1

Rationale 1: Chronic rejection may develop months to years following a transplant. The presenting manifestations of progressive azotemia, proteinuria, and hypertension are those of progressive renal failure.

Rationale 2: Acute rejection most commonly occurs in the weeks immediately following a transplant.

Rationale 3: Renal artery stenosis manifests with a bruit over the surgical anastomosis site.

Rationale 4: Pyelonephritis manifests with abdominal discomfort and low-grade fever.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 39-5

Question 28

Type: MCSA

Which intervention would be appropriate for a patient in renal failure with the diagnosis of Imbalanced Nutrition: Less than Body Requirements?

1. Provide mouth care before meals.

2. Maximize the protein content of meals and snacks.

3. Provide antiemetics after meals.

4. Weigh once per week.

Correct Answer: 1

Rationale 1: Interventions for a patient with this nursing diagnosis should include assisting with mouth care prior to meals.

Rationale 2: Patients with chronic renal failure have varying protein needs according to the individual disease process. Protein that is provided should be of high biologic value.

Rationale 3: Interventions for a patient with this nursing diagnosis should include administering antiemetics 30 to 60 minutes before meals.

Rationale 4: The patient with chronic renal failure should be weighed daily.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 39-4

Question 29

Type: MCSA

A patient is diagnosed with postrenal acute renal failure. Which finding is associated with this type of renal failure?

1. An enlarged prostate

2. Hypovolemia

3. Sepsis

4. Drug toxicity

Correct Answer: 1

Rationale 1: Causes for postrenal acute renal failure include prostatic enlargement, which obstructs urine outflow.

Rationale 2: Hypovolemia is considered a prerenal cause of acute renal failure.

Rationale 3: Sepsis is considered a prerenal cause of acute renal failure.

Rationale 4: Drug toxicity causing acute tubular necrosis is an intrarenal cause of acute renal failure.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 39-3

Question 30

Type: MCSA

The nurse is caring for a patient receiving peritoneal dialysis. After completing the exchange and draining the dialysate, the nurse observes the dialysate is cloudy. How should the nurse evaluate this finding?

1. A sign of infection

2. A sign of vascular access occlusion

3. The normal appearance of dialysate

4. A sign of possible bowel perforation

Correct Answer: 1

Rationale 1: Dialysate is typically clear; cloudy or malodorous dialysate may indicate infection.

Rationale 2: Peritoneal dialysis does not require vascular access.

Rationale 3: Dialysate is typically clear.

Rationale 4: Blood or feces in the dialysate may indicate organ or bowel perforation.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 39-6

Question 31

Type: MCMA

A patient has been diagnosed with renal cancer. The nurse would assess for which risk factors in the patients history?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Obesity

2. Under age 35

3. Cigarette smoking

4. Infertility

5. Exposure to asbestos or benzene

Correct Answer: 1,3,5

Rationale 1: There appears to be a direct correlation between obesity and an increased risk of developing renal carcinoma.

Rationale 2: There is no increased risk from being under age 35.

Rationale 3: Smoking increases the risk of renal carcinoma.

Rationale 4: There is no connection between infertility and increased risk of renal carcinoma.

Rationale 5: Occupational exposure to substances such as asbestos and benzene increases the risk of renal carcinoma.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 39-3

Question 32

Type: MCSA

The nurse, administering epoetin alfa (Epogen) to a patient on dialysis, explains that the medication will help replace which function of the kidney?

1. Treats the anemia seen in chronic renal failure patients on dialysis

2. Combats the effects of dialysis on bone marrow

3. Promotes elimination of nephrotoxic drugs from the body

4. Enhances absorption of iron and folate in the intestinal tract

Correct Answer: 1

Rationale 1: In chronic renal failure, erythropoietin production in the kidney declines, which suppresses RBC production, leading to anemia. Erythropoieisis-stimulating agents such as epoetin alfa increase RBC production.

Rationale 2: Epoetin alfa has no action on bone marrow.

Rationale 3: Epoetin alfa does not promote elimination of nephrotoxic drugs from the body.

Rationale 4: Epoetin alfa does not affect absorption of iron or folate.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 39-1

Question 33

Type: MCSA

The nurse assesses the arm of a patient with an arteriovenous fistula for the presence of which finding?

1. A bruit upon auscultation

2. A thrill upon auscultation

3. A bruit upon palpation

4. A thrill upon inspection

Correct Answer: 1

Rationale 1: A functional arteriovenous fistula is assessed for the presence of a palpable pulsation and a bruit upon auscultation.

Rationale 2: A thrill is palpated, not inspected or auscultated.

Rationale 3: A bruit is not palpated.

Rationale 4: A thrill is palpated, not inspected or auscultated.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 39-6

Question 34

Type: MCSA

The patient is scheduled for a peritoneal dialysis catheter insertion. Which information will the nurse provide prior to this procedure?

1. The insertion site will be just below your sternum.

2. You will be able to care for this catheter at home.

3. Since you are having this procedure, you will not need a kidney transplant.

4. Hemodialysis can be performed through this catheter if necessary.

5.

Correct Answer: 2

Rationale 1: These catheters are placed into the abdominal cavity.

Rationale 2: The patient or significant other is taught the care of this catheter so that dialysis is performed at home.

Rationale 3: Using peritoneal dialysis does not mean that the patient might not be a candidate for a kidney transplant at some time.

Rationale 4: There is a distinct difference between hemodialysis and peritoneal dialysis, and the access sites are not interchangeable.

Rationale 5:

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 39-6

Question 35

Type: MCMA

A patient has been admitted for treatment of nephrotic syndrome. Which assessment findings would the nurse anticipate?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Protein in the urine

2. Increased serum protein

3. Edema around the eyes

4. Ascites

5. Edema in the feet.

Correct Answer: 1,3,5

Rationale 1: Damage to the glomerular blood vessels allows protein to leak into the urine.

Rationale 2: The serum protein is decreased.

Rationale 3: Periorbital edema is a common assessment finding in patients with nephrotic syndrome.

Rationale 4: Ascites is a finding associated with liver dysfunction.

Rationale 5: Edema in dependent areas such as the feet is a common finding in patients with nephrotic syndrome.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 39-3

Osborn, Medical-Surgical Nursing, 2e, Test Bank

Copyright 2014 by Pearson Education, Inc.

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