Chapter 46: Nursing Management: Renal and Urologic Problems My Nursing Test Banks

Lewis: Medical-Surgical Nursing, 8th Edition

Chapter 46: Nursing Management: Renal and Urologic Problems

Test Bank

MULTIPLE CHOICE

1. A patient returns to the clinic with recurrent dysuria after being treated with trimethoprim and sulfamethoxazole (Bactrim) for 3 days. Which action will the nurse plan to take?

a.

Remind the patient about the need to drink 1000 mL of fluids daily.

b.

Obtain a midstream urine specimen for culture and sensitivity testing.

c.

Teach the patient to take the prescribed Bactrim for at least 3 more days.

d.

Suggest that the patient use acetaminophen (Tylenol) to treat the symptoms.

ANS: B

Since uncomplicated urinary tract infections (UTIs) are usually successfully treated with 3 days of antibiotic therapy, this patient will need a urine culture and sensitivity to determine appropriate antibiotic therapy. Tylenol would not be as effective as other over-the-counter (OTC) medications such as phenazopyridine (Pyridium) in treating dysuria. The fluid intake should be increased to at least 1800 mL/day. Since the UTI has persisted after treatment with Bactrim, the patient is likely to need a different antibiotic.

DIF: Cognitive Level: Application REF: 1123-1125 TOP: Nursing Process: Planning

MSC: NCLEX: Physiological Integrity

2. The nurse determines that instruction regarding prevention of future urinary tract infections (UTIs) for a patient with cystitis has been effective when the patient states,

a.

I can use vaginal sprays to reduce bacteria.

b.

I will drink a quart of water or other fluids every day.

c.

I will wash with soap and water before sexual intercourse.

d.

I will empty my bladder every 3 to 4 hours during the day.

ANS: D

Voiding every 3 to 4 hours is recommended to prevent UTIs. Use of vaginal sprays is dis-

couraged. The bladder should be emptied before and after intercourse, but cleaning with soap and water is not necessary. A quart of fluids is insufficient to provide adequate urine output to decrease risk for UTI.

DIF: Cognitive Level: Application REF: 1125 TOP: Nursing Process: Evaluation

MSC: NCLEX: Health Promotion and Maintenance

3. Which information will the nurse include when teaching the patient with a urinary tract infection (UTI) about the use of phenazopyridine (Pyridium)?

a.

Take the medication for at least 7 days.

b.

Use sunscreen while taking the Pyridium.

c.

The urine may turn a reddish-orange color.

d.

Use the Pyridium before sexual intercourse.

ANS: C

Patients should be taught that Pyridium will color the urine deep orange. Urinary analgesics should only be needed for a few days until the prescribed antibiotics decrease the bacterial count. Taking Pyridium before intercourse will not be helpful in reducing the risk for UTI. Pyridium does not cause photosensitivity.

DIF: Cognitive Level: Application REF: 1124-1125

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

4. A 72-year-old who has benign prostatic hyperplasia is admitted to the hospital with chills, fever, and vomiting. Which finding by the nurse will be most helpful in determining whether the patient has an upper urinary tract infection (UTI)?

a.

Suprapubic pain

b.

Bladder distention

c.

Foul-smelling urine

d.

Costovertebral tenderness

ANS: D

Costovertebral tenderness is characteristic of pyelonephritis. The other symptoms are characteristic of lower UTI and are likely to be present if the patient also has an upper UTI.

DIF: Cognitive Level: Application REF: 1128

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

5. After teaching a patient with interstitial cystitis about management of the condition, the nurse determines that further instruction is needed when the patient says,

a.

I will have to stop having coffee and orange juice for breakfast.

b.

I should start taking a high potency multiple vitamin every morning.

c.

I will buy some calcium glycerophosphate (Prelief) at the pharmacy.

d.

I should call the doctor about increased bladder pain or odorous urine.

ANS: B

High-potency multiple vitamins may irritate the bladder and increase symptoms. The other patient statements indicate good understanding of the teaching.

DIF: Cognitive Level: Application REF: 1130-1131 TOP: Nursing Process: Evaluation

MSC: NCLEX: Physiological Integrity

6. When admitting a patient with acute glomerulonephritis, it is most important that the nurse ask the patient about

a.

recent sore throat and fever.

b.

history of high blood pressure.

c.

frequency of bladder infections.

d.

family history of kidney stones.

ANS: A

Acute glomerulonephritis frequently occurs after a streptococcal infection such as strep throat. It is not caused by hypertension, urinary tract infection (UTI), or kidney stones.

DIF: Cognitive Level: Application REF: 1131-1132

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

7. Which finding by the nurse for a patient admitted with glomerulonephritis indicates that treatment has been effective?

a.

The patient denies pain with voiding.

b.

The urine dipstick is negative for nitrites.

c.

Peripheral and periorbital edema is resolved.

d.

The antistreptolysin-O (ASO) titer is decreased.

ANS: C

Since edema is a common clinical manifestation of glomerulonephritis, resolution of the edema indicates that the prescribed therapies have been effective. Antibodies to streptococcus will persist after a streptococcal infection. Nitrites will be negative and the patient will not experience dysuria since the patient does not have a urinary tract infection.

DIF: Cognitive Level: Application REF: 1131-1133 TOP: Nursing Process: Evaluation

MSC: NCLEX: Physiological Integrity

8. A patient with nephrotic syndrome develops flank pain. The nurse will anticipate teaching the patient about treatment with

a.

antibiotics.

b.

anticoagulants.

c.

corticosteroids.

d.

antihypertensives.

ANS: B

Flank pain in a patient with nephrosis suggests a renal vein thrombosis, and anticoagulation is needed. Antibiotics are used to treat a patient with flank pain caused by pyelonephritis. Antihypertensives are used if the patient has high blood pressure. Corticosteroids may be used to treat nephrotic syndrome but will not resolve a thrombosis.

DIF: Cognitive Level: Application REF: 1133-1134 TOP: Nursing Process: Planning

MSC: NCLEX: Physiological Integrity

9. A patient is admitted to the hospital with new onset nephrotic syndrome. Which assessment data will the nurse expect to find related to this illness?

a.

Poor skin turgor

b.

High urine ketones

c.

Recent weight gain

d.

Low blood pressure

ANS: C

The patient with a nephrotic syndrome will have weight gain associated with edema. Hypertension is a clinical manifestation of nephrotic syndrome. Skin turgor is normal because of the edema. Urine protein is high.

DIF: Cognitive Level: Comprehension REF: 1132-1134

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

10. A patients renal calculus is analyzed as being very high in uric acid. To prevent recurrence of stones, the nurse teaches the patient to avoid eating

a.

milk and dairy products.

b.

legumes and dried fruits.

c.

organ meats and sardines.

d.

spinach, chocolate, and tea.

ANS: C

Organ meats and fish such as sardines increase purine levels and uric acid. Spinach, chocolate, and tomatoes should be avoided in patients who have oxalate stones. Milk, dairy products, legumes, and dried fruits may increase the incidence of calcium-containing stones.

DIF: Cognitive Level: Application REF: 1139

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

11. To prevent the recurrence of renal calculi, the nurse teaches the patient to

a.

use a filter to strain all urine.

b.

avoid dietary sources of calcium.

c.

drink diuretic fluids such as coffee.

d.

have 2000 to 3000 mL of fluid a day.

ANS: D

A fluid intake of 2000 to 3000 mL daily is recommended to help flush out minerals before stones can form. Avoidance of calcium is not usually recommended for patients with renal calculi. Coffee tends to increase stone recurrence. There is no need for a patient to strain all urine routinely after a stone has passed, and this will not prevent stones.

DIF: Cognitive Level: Application REF: 1138-1139

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

12. When planning teaching for a patient with benign nephrosclerosis the nurse should include instructions regarding

a.

monitoring and recording blood pressure.

b.

obtaining and documenting daily weights.

c.

measuring daily intake and output amounts.

d.

preventing bleeding caused by anticoagulants.

ANS: A

Hypertension is the major symptom of nephrosclerosis. Measurements of intake and output and daily weights are not necessary unless the patient develops renal insufficiency. Anticoagulants are not used to treat nephrosclerosis.

DIF: Cognitive Level: Application REF: 1141-1142 TOP: Nursing Process: Planning

MSC: NCLEX: Physiological Integrity

13. A 32-year-old patient is diagnosed with polycystic kidney disease. Which information is most appropriate for the nurse to include in teaching at this time?

a.

Importance of genetic counseling

b.

Complications of renal transplantation

c.

Methods for treating chronic and severe pain

d.

Differences between hemodialysis and peritoneal dialysis

ANS: A

Because a 32-year-old patient may be considering having children, the nurse should include information about genetic counseling when teaching the patient. The well-managed patient will not need to choose between hemodialysis and peritoneal dialysis or know about the effects of transplantation for many years. There is no indication that the patient has chronic pain.

DIF: Cognitive Level: Application REF: 1143

TOP: Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance

14. When assessing a 30-year-old man who complains of a feeling of incomplete bladder emptying and a split, spraying urine stream, the nurse asks about a history of

a.

bladder infection.

b.

recent kidney trauma.

c.

gonococcal urethritis.

d.

benign prostatic hyperplasia.

ANS: C

The patients clinical manifestations are consistent with urethral strictures, a possible complication of gonococcal urethritis. These symptoms are not consistent with benign prostatic hyperplasia, kidney trauma, or bladder infection.

DIF: Cognitive Level: Application REF: 1141

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

15. After obtaining the health history for a 25-year-old who smokes two packs of cigarettes daily, the nurse will plan to do teaching about the increased risk for

a.

kidney stones.

b.

bladder cancer.

c.

bladder infection.

d.

interstitial cystitis.

ANS: B

Cigarette smoking is a risk factor for bladder cancer. The patients risk for developing interstitial cystitis, urinary tract infection (UTI), or kidney stones will not be reduced by quitting smoking.

DIF: Cognitive Level: Application REF: 1145-1146 TOP: Nursing Process: Planning

MSC: NCLEX: Health Promotion and Maintenance

16. A 78-year-old who has been admitted to the hospital with dehydration is confused and incontinent of urine. Which nursing action will be best to include in the plan of care?

a.

Apply absorbent incontinent pads.

b.

Restrict fluids after the evening meal.

c.

Insert an indwelling catheter until the symptoms have resolved.

d.

Assist the patient to the bathroom every 2 hours during the day.

ANS: D

In older or confused patients, incontinence may be avoided by using scheduled toileting times. Indwelling catheters increase the risk for urinary tract infection (UTI). Incontinent pads increase the risk for skin breakdown. Restricting fluids is not appropriate in a patient with dehydration.

DIF: Cognitive Level: Application REF: 1151-1152 TOP: Nursing Process: Planning

MSC: NCLEX: Physiological Integrity

17. A 62-year-old asks the nurse for a perineal pad, stating that laughing or coughing causes leakage of urine. Which intervention is most appropriate to include in the care plan?

a.

Assist the patient to the bathroom q3hr.

b.

Place a commode at the patients bedside.

c.

Demonstrate how to perform the Cred maneuver.

d.

Teach the patient how to perform Kegel exercises.

ANS: D

Exercises to strengthen the pelvic floor muscles will help reduce stress incontinence. The Cred maneuver is used to help empty the bladder for patients with overflow incontinence. Placing the commode close to the bedside and assisting the patient to the bathroom are helpful for functional incontinence.

DIF: Cognitive Level: Application REF: 1148 TOP: Nursing Process: Planning

MSC: NCLEX: Health Promotion and Maintenance

18. Following rectal surgery, a patient voids about 50 mL of urine every 30 to 60 minutes. Which nursing action is most appropriate?

a.

Use an ultrasound scanner to check the postvoiding residual.

b.

Monitor the patients intake and output over the next few hours.

c.

Have the patient take small amounts of fluid frequently throughout the day.

d.

Reassure the patient that this is normal after rectal surgery because of anesthesia.

ANS: A

An ultrasound scanner can be used to check for residual urine after the patient voids. Because the patients history and clinical manifestations are consistent with overflow incontinence, it is not appropriate to have the patient drink small amounts. Although overflow incontinence is not unusual after surgery, the nurse should intervene to correct the physiologic problem, not just reassure the patient. The patient may develop reflux into the renal pelvis as well as discomfort from a full bladder if the nurse waits to address the problem for several hours.

DIF: Cognitive Level: Application REF: 1146-1147 | 1154

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

19. A patient in the hospital has a history of functional urinary incontinence. Which nursing action will be included in the plan of care?

a.

Place a bedside commode near the patients bed.

b.

Demonstrate the use of the Cred maneuver to the patient.

c.

Use an ultrasound scanner to check postvoiding residuals.

d.

Teach the use of Kegel exercises to strengthen the pelvic floor.

ANS: A

Modifications in the environment make it easier to avoid functional incontinence. Checking for residual urine and performing the Cred maneuver are interventions for overflow incontinence. Kegel exercises are useful for stress incontinence.

DIF: Cognitive Level: Application REF: 1148 TOP: Nursing Process: Planning

MSC: NCLEX: Physiological Integrity

20. After the home health nurse teaches a patient with a neurogenic bladder how to use intermittent catheterization for bladder emptying, which patient statement indicates that the teaching has been effective?

a.

I will use a sterile catheter and gloves for each time I self-catheterize.

b.

I will clean the catheter carefully before and after each catheterization.

c.

I will need to buy seven new catheters weekly and use a new one every day.

d.

I will need to take prophylactic antibiotics to prevent any urinary tract infections.

ANS: B

Patients who are at home can use a clean technique for intermittent self-catheterization and change the catheter every 7 days. There is no need to use a new catheter every day, to use sterile catheters, or to take prophylactic antibiotics.

DIF: Cognitive Level: Application REF: 1154 TOP: Nursing Process: Evaluation

MSC: NCLEX: Physiological Integrity

21. Which action will the nurse include in the plan of care for a patient who has had a ureterolithotomy and has a left ureteral catheter and a urethral catheter in place?

a.

Provide education about home care for both catheters.

b.

Apply continuous steady tension to the ureteral catheter.

c.

Clamp the ureteral catheter unless output from the urethral catheter stops.

d.

Call the health care provider if the ureteral catheter output drops suddenly.

ANS: D

The health care provider should be notified if the ureteral catheter output decreases since obstruction of this catheter may result in an increase in pressure in the renal pelvis. Tension on the ureteral catheter should be avoided in order to prevent catheter displacement. To avoid pressure in the renal pelvis, the catheter is not clamped. Since the patient is not usually discharged with a ureteral catheter in place, patient teaching about both catheters is not needed.

DIF: Cognitive Level: Application REF: 1153-1154 TOP: Nursing Process: Planning

MSC: NCLEX: Physiological Integrity

22. A patient who has bladder cancer had a cystectomy with creation of an Indiana pouch. Which topic will be included in patient teaching?

a.

Application of ostomy appliances

b.

Catheterization technique and schedule

c.

Analgesic use before emptying the pouch

d.

Use of barrier products for skin protection

ANS: B

The Indiana pouch enables the patient to self-catheterize every 4 to 6 hours. There is no need for an ostomy device or barrier products. Catheterization of the pouch is not painful.

DIF: Cognitive Level: Application REF: 1155-1156

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

23. Two days after surgery for an ileal conduit, the patient will not look at the stoma or participate in care. The patient insists that no one but the ostomy nurse specialist care for the stoma. The nurse identifies a nursing diagnosis of

a.

anxiety related to effects of procedure on lifestyle.

b.

disturbed body image related to change in body function.

c.

readiness for enhanced coping related to need for information.

d.

self-care deficit, toileting, related to denial of altered body function.

ANS: B

The patients unwillingness to look at the stoma or participate in care indicates that disturbed body image is the best diagnosis. No data suggest that the impact on lifestyle is a concern for the patient. The patient does not appear to be ready for enhanced coping. The patients insistence that only the ostomy nurse care for the stoma indicates that denial is not present.

DIF: Cognitive Level: Application REF: 1157 | 1159-1160 | 1158-1159

TOP: Nursing Process: Diagnosis MSC: NCLEX: Psychosocial Integrity

24. A patient who has had a transurethral resection with fulguration for bladder cancer 3 days previously calls the nurse at the urology clinic. Which information given by the patient is most important to report to the health care provider?

a.

The patient is using opioids for pain.

b.

The patient has noticed clots in the urine.

c.

The patient is very anxious about the cancer.

d.

The patient is voiding every 4 hours at night.

ANS: B

Clots in the urine are not expected and require further follow-up. Voiding every 4 hours, use of opioids for pain, and anxiety are typical after this procedure.

DIF: Cognitive Level: Application REF: 1145-1146

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

25. A patient with bladder cancer is scheduled for intravesical chemotherapy. In preparation for the treatment the nurse will teach the patient about

a.

premedicating to prevent nausea.

b.

where to obtain wigs and scarves.

c.

the importance of oral care during treatment.

d.

the need to empty the bladder before treatment.

ANS: D

The patient will be asked to empty the bladder before instillation of the chemotherapy. Systemic side effects are not experienced with intravesical chemotherapy.

DIF: Cognitive Level: Application REF: 1146

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

26. Which nursing action will be most helpful in decreasing the risk for hospital-acquired infection (HAI) of the urinary tract in patients admitted to the hospital?

a.

Avoid unnecessary catheterizations.

b.

Encourage adequate oral fluid intake.

c.

Test urine with a dipstick daily for nitrites.

d.

Provide thorough perineal hygiene to patients.

ANS: A

Since catheterization bypasses many of the protective mechanisms that prevent urinary tract infection (UTI), avoidance of catheterization is the most effective means of reducing HAI. The other actions will also be helpful, but are not as useful as decreasing urinary catheter use.

DIF: Cognitive Level: Application REF: 1125-1127 TOP: Nursing Process: Planning

MSC: NCLEX: Physiological Integrity

27. When assessing the patient who has a lower urinary tract infection (UTI), the nurse will initially ask about

a.

nausea.

b.

flank pain.

c.

poor urine output.

d.

pain with urination.

ANS: D

Pain with urination is a common symptom of a lower UTI. Urine output does not decrease, but frequency may be experienced. Flank pain and nausea are associated with an upper UTI.

DIF: Cognitive Level: Application REF: 1123-1124

OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

MSC: NCLEX: Physiological Integrity

28. Which assessment finding for a patient who has just been admitted with acute pyelonephritis is most important for the nurse to report to the health care provider?

a.

Foul-smelling urine

b.

Complaint of flank pain

c.

Blood pressure 88/45 mm Hg

d.

Temperature 100.1 F (57.8 C)

ANS: C

The low blood pressure indicates that urosepsis and septic shock may be occurring and should be immediately reported. The other findings are typical of pyelonephritis.

DIF: Cognitive Level: Application REF: 1126

OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

MSC: NCLEX: Physiological Integrity

29. A patient who is diagnosed with nephrotic syndrome has 3+ ankle and leg edema and ascites. Which nursing diagnosis is a priority for the patient?

a.

Excess fluid volume related to low serum protein levels

b.

Activity intolerance related to increased weight and fatigue

c.

Disturbed body image related to peripheral edema and ascites

d.

Altered nutrition: less than required related to protein restriction

ANS: A

The patient has massive edema, so the priority problem at this time is the excess fluid volume. The other nursing diagnoses also are appropriate, but the focus of nursing care should be resolution of the edema and ascites.

DIF: Cognitive Level: Application REF: 1133-1135

OBJ: Special Questions: Prioritization TOP: Nursing Process: Diagnosis

MSC: NCLEX: Physiological Integrity

30. An 88-year-old with benign prostatic hyperplasia (BPH) has a markedly distended bladder and is agitated and confused. Which of the following interventions prescribed by the health care provider should the nurse implement first?

a.

Insert a urinary retention catheter.

b.

Schedule an intravenous pyelogram.

c.

Administer lorazepam (Ativan) 0.5 mg PO.

d.

Draw blood for blood urea nitrogen (BUN) and creatinine testing.

ANS: A

The patients history and clinical manifestations are consistent with acute urinary retention, and the priority action is to relieve the retention by catheterization. The BUN and creatinine measurements can be obtained after the catheter is inserted. The patients agitation may resolve once the bladder distention is corrected, and sedative drugs should be used cautiously in older patients. The IVP is an appropriate test, but does not need to be done urgently.

DIF: Cognitive Level: Application REF: 1135-1136

OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

MSC: NCLEX: Physiological Integrity

31. A patient with renal calculi is hospitalized with gross hematuria and severe colicky left flank pain. Which nursing action will be of highest priority at this time?

a.

Encourage oral fluid intake.

b.

Administer prescribed analgesics.

c.

Monitor temperature every 4 hours.

d.

Give antiemetics as needed for nausea.

ANS: B

Although all of the nursing actions may be used for patients with renal lithiasis, the patients presentation indicates that management of pain is the highest priority action. If the patient has urinary obstruction, increasing oral fluids may increase the symptoms. There is no evidence of infection or nausea.

DIF: Cognitive Level: Application REF: 1137-1138 | 1139-1141 | 1140

OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

MSC: NCLEX: Physiological Integrity

32. Which nursing action should the nurse who is caring for a patient who has had an ileal conduit for several years delegate to nursing assistive personnel (NAP)?

a.

Assess for symptoms of urinary tract infection (UTI).

b.

Change the ostomy appliance.

c.

Choose the appropriate ostomy bag.

d.

Monitor the appearance of the stoma.

ANS: B

Changing the ostomy appliance for a stable patient could be done by NAP. Assessments of the site, choosing the appropriate ostomy bag, and assessing for (UTI) symptoms require more education and scope of practice and should be done by the RN.

DIF: Cognitive Level: Application REF: 1157 | 1159-1160 | 1158

OBJ: Special Questions: Delegation TOP: Nursing Process: Planning

MSC: NCLEX: Safe and Effective Care Environment

33. When the nurse is caring for a patient who has had left-sided extracorporeal shock wave lithotripsy, which assessment finding is most important to report to the health care provider?

a.

Blood in urine

b.

Left flank pain

c.

Left flank bruising

d.

Drop in urine output

ANS: D

Because lithotripsy breaks the stone into small sand, which could cause obstruction, it is important to report a drop in urine output. Left flank pain, bruising, and hematuria are common after lithotripsy.

DIF: Cognitive Level: Application REF: 1138-1139

OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

MSC: NCLEX: Physiological Integrity

34. Following an open loop resection and fulguration of the bladder, a patient is unable to void. Which nursing action should be implemented first?

a.

Insert a straight catheter and drain the bladder.

b.

Assist the patient to take a 15-minute sitz bath.

c.

Encourage the patient to drink several glasses of water.

d.

Teach the patient how to do isometric perineal exercises.

ANS: B

Sitz baths will relax the perineal muscles and promote voiding. Although the patient should be encouraged to drink fluids and Kegel exercises are helpful in the prevention of incontinence, these activities would not be helpful for a patient experiencing retention. Catheter insertion increases the risk for urinary tract infection (UTI) and should be avoided when possible

DIF: Cognitive Level: Application REF: 1146

OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

MSC: NCLEX: Physiological Integrity

35. The nurse observes nursing assistive personnel (NAP) taking the following actions when caring for a patient with a retention catheter. Which action requires that the nurse intervene?

a.

Taping the catheter to the skin on the patients upper inner thigh

b.

Cleaning around the patients urinary meatus with soap and water

c.

Using an alcohol-based hand cleaner before performing catheter care

d.

Disconnecting the catheter from the drainage tube to obtain a specimen

ANS: D

The catheter should not be disconnected from the drainage tube because this increases the risk for urinary tract infection (UTI). The other actions are appropriate and do not require any intervention.

DIF: Cognitive Level: Application REF: 1152-1154

OBJ: Special Questions: Delegation TOP: Nursing Process: Assessment

MSC: NCLEX: Safe and Effective Care Environment

36. A patient undergoes a nephrectomy after having massive trauma to the kidney. Which assessment finding obtained postoperatively is most important to communicate to the surgeon?

a.

Blood pressure is 102/58.

b.

Incisional pain level is 8/10.

c.

Urine output is 20 mL/hr for 2 hours.

d.

Crackles are heard at both lung bases.

ANS: C

Because the urine output should be at least 0.5 mL/kg/hr, a 40 mL output for 2 hours indicates that the patient may have decreased renal perfusion because of bleeding, inadequate fluid intake, or obstruction at the suture site. The blood pressure requires ongoing monitoring but does not indicate inadequate perfusion at this time. The patient should cough and deep breathe, but the crackles do not indicate a need for an immediate change in therapy. The incisional pain should be addressed, but this is not as potentially life threatening as decreased renal perfusion. In addition, the nurse can medicate the patient for pain.

DIF: Cognitive Level: Application REF: 1154-1155

OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

MSC: NCLEX: Physiological Integrity

37. Which assessment finding for a patient who has had a cystectomy with an ileal conduit the previous day is most important for the nurse to communicate to the physician?

a.

Cloudy appearing urine

b.

Hypotonic bowel sounds

c.

Heart rate 102 beats/minute

d.

Continuous drainage from stoma

ANS: C

Tachycardia may indicate infection, hemorrhage, or hypovolemia, which are all serious complications of this surgery. The urine from an ileal conduit normally contains mucus and is cloudy. Hypotonic bowel sounds are expected after bowel surgery. Continuous drainage of urine from the stoma is normal.

DIF: Cognitive Level: Application REF: 1157 | 1159-1160 | 1158-1159

OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

MSC: NCLEX: Physiological Integrity

38. A 26-year-old patient with a history of polycystic kidney disease is admitted to the surgical unit after having knee surgery. Which of the routine postoperative orders is most important for the nurse to discuss with the health care provider?

a.

Infuse 5% dextrose in normal saline at 75 mL/hr.

b.

Order regular diet after patient is awake and alert.

c.

Give ketorolac (Toradol) 10 mg PO PRN for pain.

d.

Obtain blood urea nitrogen (BUN), creatinine, and electrolytes in 2 hours.

ANS: C

The NSAIDs should be avoided in patients with decreased renal function because nephrotoxicity is a potential adverse effect. The other orders do not need any clarification or change.

DIF: Cognitive Level: Application REF: 1142-1143

OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

MSC: NCLEX: Physiological Integrity

39. Which information noted by the nurse when caring for a patient with a bladder infection is most important to report to the health care provider?

a.

Dysuria

b.

Hematuria

c.

Left-sided flank pain

d.

Temperature 100.1 F

ANS: C

Flank pain indicates that the patient may have developed pyelonephritis as a complication of the bladder infection. The other clinical manifestations are consistent with a lower urinary tract infection (UTI).

DIF: Cognitive Level: Application REF: 1132-1133

OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

MSC: NCLEX: Physiological Integrity

Mosby items and derived items 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.

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