Question 1

The nurse is caring for a 68-year-old male client following a laparoscopic cholecystectomy 8 hours ago. The client has not urinated since surgery. Which would be the most appropriate initial intervention?

Accepted Answer

Urinary retention occurs frequently after surgery due to administration of opioids (eg, morphine) and anesthesia, and in older men, who often have an enlarged prostate gland or benign prostatic hyperplasia (BPH). Up to 50% of men over age 60 have an enlarged prostate. Body position can also contribute to urinary retention. Most men are used to urinating when standing up; therefore, the nurse or assistive personnel should help the client out of bed rather than offer a urinal for use in bed (Option B). Providing privacy may also aid in relaxation and urination. benign prostatic hyperplasia (BPH) (Option A) The second intervention should be a bladder scan. If the client is unable to urinate, an ultrasound scan can be used to noninvasively assess the volume of urine in the bladder. It can also be used to determine the residual bladder volume after the client has urinated to assess the amount of retention. (Option C) An indwelling catheter is not currently indicated for this client. Catheter-associated urinary tract infection (CAUTI) is a significant hospital-acquired infection. The risk of CAUTI can be reduced by using an indwelling catheter only when other interventions have failed to produce desired outcomes. (Option D) Intermittent catheterization would be the third intervention if the client has been unable to urinate or has significant urinary retention (>300-400 mL). Educational objective: Urinary retention after surgery is common and often made worse by existing benign prostatic hyperplasia in older men. If a client has difficulty urinating, the nurse should first try noninvasive methods to help the client urinate in a normal position and provide privacy to help the client relax.

Question 2

The nurse caring for multiple clients who underwent renal system diagnostic testing should report which post-procedure finding to the health care provider?

Accepted Answer

Various diagnostic tests, including bladder scans, urine cultures, cystoscopy, renal arteriograms, and renal scans, assess the renal system. It is necessary to understand the purpose and procedures for each examination when evaluating complications arising from these assessments. Portable ultrasonic bladder scanners are used at the bedside to determine the amount of residual urine in the bladder. Amounts >100 mL should be reported as the client may be experiencing urinary retention (Option A). (Option B) A cystoscope is inserted through the urethra to directly visualize the bladder wall and urethra. Irritation of the urethral and bladder lining from the insertion and manipulation of the cystoscope may cause a slight burning sensation with voiding for a day or two. (Option C) Renal arteriogram is a radiologic test performed to visualize renal blood vessels to detect abnormalities (renal artery stenosis or aneurysm). A contrast medium is injected into the femoral artery; therefore, the client should be taught to increase fluid intake after the procedure to flush the dye from the body. Increased output is an expected finding. (Option D) Urine is sterile, but the urethra contains bacteria and a few white blood cells. Less than 10,000 organisms/mL is a normal value for urine culture. Values >10,000 organisms/mL indicate urinary tract infection (UTI). Educational objective: Residual urine volume of >100 mL on bladder scan may indicate urinary retention. Urine culture showing values >10,000 organisms/mL can suggest UTI. Burning sensation is common after cystoscopy. Renal arteriogram is performed with a contrast agent; excretion of the dye with oral and intravenous hydration is recommended to prevent kidney injury.

Question 3

The nurse cares for a client scheduled for a percutaneous left kidney biopsy as an outpatient.  Which intervention should the nurse include in the client's post-procedure care plan?

Accepted Answer

A kidney biopsy involves obtaining a tissue sample for pathological evaluation to determine the cause of certain kidney diseases (eg, nephritis, transplant rejection). The kidney has extensive vasculature (similar to the liver); therefore, bleeding from the biopsy site is the major complication following a percutaneous kidney biopsy. Before the procedure, the client must give informed consent and discontinue all anticoagulants (eg, heparin, warfarin, rivaroxaban) and antiplatelet agents (eg, aspirin, clopidogrel, nonsteroidal anti-inflammatory drugs) for at least one week. The client should be typed and crossmatched for blood (although the need for a transfusion is rare). Blood pressure should be well-controlled. After the procedure, the nurse should monitor vital signs at least every 15 minutes for the first hour as tachycardia, tachypnea, and hypotension can indicate blood loss. The nurse should also assess the puncture site dressing for bleeding (Option D). (Option A) Blood urea nitrogen (BUN) and creatinine levels would not change significantly within 30-60 minutes. These are usually measured once every 24 hours and rarely every 12 hours. (Option B) Insertion of an indwelling urinary catheter is not necessary to perform a kidney biopsy and is not part of the usual protocol. (Option C) Post-procedure, the client should be positioned on the affected (left) side for 30-60 minutes to provide pressure and help prevent bleeding. The client is usually placed in the prone position during the procedure to facilitate access to the kidney. Educational objective: Bleeding is a complication following a kidney biopsy. For assessment and prevention of this complication the nurse should monitor vital signs frequently, assess the biopsy site and dressing, and have the client positioned on the affected side for 30-60 minutes and on bed rest for 24 hours.

Question 4

The nurse is caring for a client with an ileal conduit. While assisting the client in removing the external pouch, the nurse observes that the stoma appears bluish grey. What is the nurse's best action?

Accepted Answer

11ecbb05_ca7d_4303_b433_197006e50501_MD0009_00 An ileal conduit is a surgical technique that uses an excised piece of the client's ileum to create an incontinent urinary diversion. The client's ureters are connected to the ileal conduit, which is used to create an abdominal stoma that allows the passage of urine. A healthy stoma should be pink to brick-red and moist, indicating vascularity and viability. If the stoma is dusky or any shade of blue, the nurse should suspect impaired perfusion and contact the HCP immediately. This finding is considered a medical emergency (Option D). (Option A) Infection is a potential complication; signs and symptoms of infection may include fever, elevated white blood cell count, odor, and delayed healing. A bluish grey color indicates impaired perfusion, not infection. (Option B) Although the nurse will document the findings and monitor for changes, lack of perfusion to the stoma is an emergency that must be reported immediately. (Option C) Applying an appropriate-size pouching system (approximately 0.1 in [0.25 cm] larger than the stoma) prevents decreased perfusion and skin irritation. Using a larger drainage bag, especially at night, prevents urine backflow through the stoma and reduces the risk for infection. These are important concepts of stoma care but are not the priority at this time. Educational objective: Stoma care involves frequent nursing assessment for signs of potential complications such as impaired perfusion, infection, and wound dehiscence. The stoma should be pink to brick-red and moist. Suspected impaired perfusion is considered a surgical emergency and should be reported immediately.

Question 5

A client suffering from bladder prolapse and subsequent stress urinary incontinence has discussed treatment options with the health care provider (HCP).  The nurse evaluates that the client understands support pessary use when the client makes which statement?

Accepted Answer

11ecbb05_ca82_9a38_b433_950c2ea669b6_MD0009_00 A pessary is a vaginal device that provides support for the bladder. Clients can remain sexually active while wearing a pessary. They are fitted for the proper type and size by an HCP in the office. Surgery is not required for pessary placement; clients who are able can insert and remove the pessary themselves (Option A). If a pessary or other treatment (eg, pelvic muscle exercises, estrogen replacement therapy) is ineffective, reconstructive surgery may be indicated. (Option C) Clients who are able to remove and reinsert the pessary on their own will have the choice to remove it weekly, possibly even nightly, for cleaning. Clients who are sexually active may prefer to remove the pessary prior to intercourse, although this is not necessary. When the client cannot remove the pessary regularly, removal by an HCP at 2- to 3-month intervals is recommended. (Option D) Increased vaginal discharge is a common side effect. However, if an odor is present, the client should be instructed to notify the HCP to be treated for a possible infection. Educational objective: A pessary is a vaginal support device recommended for pelvic organ prolapse. Pessaries are fitted by an HCP; many clients can then remove, clean, and replace these themselves. Clients can remain sexually active with a pessary in place.

Question 6

The evening shift nurse reviews the preoperative checklist and latest serum laboratory values for an elderly client with a ruptured diverticulum who is scheduled for surgery in the early morning. Which laboratory value is most important for the nurse to report to the health care provider?

Accepted Answer

Creatinine level of 2.5 mg/dL (221 µmol/L) is the most important abnormal value (normal 0.6-1.3 mg/dL [53-115 µmol/L]) for the nurse to report to the health care provider. An elevated creatinine level increases the risk for intra- and postoperative complications. Nothing-by-mouth (NPO) status preoperatively, dehydration (ie, fluid shift from peritonitis), intraoperative fluid losses, antibiotic therapy, and advanced age affect renal function and increase the risk for postoperative exacerbation of kidney injury in this client. (Option B) Potassium level 3.5 mEq/L (3.5 mmol/L) is within normal limits (3.5-5.0 mEq/L [3.5-5.0 mmol/L]). (Option C) Sodium level 134 mEq/L (134 mmol/L) is decreased (normal 135-145 mEq/L [135-145 mmol/L]) but is most likely related to NPO status and fluid shift from peritonitis. (Option D) Elevated White blood cell count (normal 4,000-11,000/mm³ [4.0-11.0 ×10⁹/L]) is an expected finding related to ruptured diverticulum and peritonitis. Educational objective: NPO status preoperatively, dehydration, intraoperative fluid losses, antibiotic therapy, and advanced age can negatively affect renal function. An elevated serum creatinine level preoperatively increases the risk for postoperative kidney injury.

Question 7

A client who was discharged following a prostatectomy performed 6 days ago calls the clinic and reports passing some small blood clots and experiencing a decreased urinary stream. What is the nurse's best response?

Accepted Answer

11ecbb05_ca82_4c17_b433_7119c1eb3e71_MD0009_00 A prostatectomy uses either minimally invasive or open surgical techniques to remove all or part of the prostate gland for clients with related disorders (eg, cancer, benign prostatic hyperplasia). For up to 36 hours after surgery, small blood clots may occur, although they should not impair the urine stream. Consistent passage of clots after this time could indicate a postoperative complication. Signs of such complications (eg, reduced urine stream, persistent bleeding/blood clots, urinary retention, fever, dysuria) after discharge should be evaluated by the health care provider for further treatment (Option A). (Option B) The presence of blood clots 6 days after surgery is not normal and may indicate bleeding from the prostatic fossa. This client requires further evaluation. (Option C) Clients should avoid the Valsalva maneuver for up to 8 weeks after prostatectomy because the exerted pressure may injure the healing tissue, causing hematuria. (Option D) Maintaining adequate fluid intake helps prevent blood clot formation. However, this client is reporting blood clots with a decreased urinary stream and needs further evaluation. Educational objective: Prostatectomy uses either minimally invasive or open surgical techniques to remove all or part of the prostate. Signs of complications (eg, reduced stream, persistent bleeding/blood clots, retention, fever, dysuria) after discharge should be evaluated by the health care provider for further treatment.

Question 8

When a client diagnosed with acute urinary retention is emergently catheterized, the nurse should initially assess for which priority manifestation that may occur as a result of the catheterization?

Accepted Answer

Acute urinary retention is best treated with rapid, complete bladder decompression rather than the intermittent urine drainage that is limited to 500 to 1000 mL at a time. Rapid decompression can be associated with hematuria, hypotension, and postobstructive diuresis (Option B). However, these are rarely clinically significant if appropriate supportive care is administered, whereas inability to relieve the obstruction can be associated with infection and kidney injury (Option C). (Option A) Dysuria from catheterization can be treated with analgesics or antispasmodic medications. Maintaining perfusion and adequate blood pressure is the priority concern. (Option D) With sudden release of bladder obstruction, cardiovascular autonomic activity occurs and the blood pressure and heart rate are reduced due to the excitation of the parasympathetic system. Educational objective: Acute urinary retention is best treated with rapid complete bladder decompression. The nurse should carefully assess for hypotension and bradycardia, which are potential complications.

Question 9

The nurse gathers a health history from a 58-year-old male client with acute urinary retention. Which of the following questions should the nurse ask to aid in assessing for benign prostatic hyperplasia? Select all that apply.

Accepted Answer

11ecbb05_ca81_88c6_b433_4bc920612634_MD0009_00 With increasing age (typically age >50), male clients experience hormone changes that can lead to prostate enlargement, known as benign prostatic hyperplasia (BPH). BPH is often not diagnosed until it begins to compress the surrounding bladder and urethra, causing voiding difficulties and abnormalities. Clients with BPH exhibit the following signs and symptoms: Urinary retention Sensation of incomplete emptying and/or increased urgency to void (Option A) Straining or difficulty initiating voiding (hesitancy) (Option B) Weak and/or intermittent stream of urine during voiding (Option E) Frequent voiding patterns throughout the day (eg, urinating more than once in 2 hours) and night (nocturia) (Option D) (Option C) Frequency of sexual intercourse is unrelated to urinary retention and BPH in the male client. Educational objective: Benign prostatic hyperplasia (BPH) occurs with increasing age (usually in men age >50) and is often undiagnosed until voiding difficulties and abnormalities are observed. Typical BPH symptoms include acute urinary retention, voiding urgency, incomplete emptying, straining to void, weak urinary stream, urinary frequency, and nocturia.

Question 10

A sexually active female client has had 3 urinary tract infections (UTIs) in 12 months. Which instructions should the nurse include in teaching the client how to prevent UTI recurrence? Select all that apply.

Accepted Answer

The nurse should encourage a sexually active female client to implement the following interventions to help prevent recurrent UTIs: Take all antibiotics as prescribed even if symptoms have improved as bacteria may still be presentIncrease fluid intake; this dilutes the urine (minimizing bladder irritation), promotes frequent urination, and prevents urinary stasis. The client should void at least every 2-4 hours. Some health care providers recommend drinking cranberry juice as it inhibits bacterial attachment to the bladder wall, but there is no clinical evidence to support its effectiveness in preventing UTIs (Option B).Wipe from front to back to prevent introducing bacteria from the vagina and anus into the urethraAvoid synthetic fabrics as these materials (eg, nylon, spandex) seal in moisture and create an environment conducive to bacterial proliferation; cotton underwear is recommended instead (Option F).Void after sexual intercourse to flush out bacteria that may have entered the urethra (Option E). Take all antibiotics as prescribed even if symptoms have improved as bacteria may still be present Increase fluid intake; this dilutes the urine (minimizing bladder irritation), promotes frequent urination, and prevents urinary stasis. The client should void at least every 2-4 hours. Some health care providers recommend drinking cranberry juice as it inhibits bacterial attachment to the bladder wall, but there is no clinical evidence to support its effectiveness in preventing UTIs (Option B). Wipe from front to back to prevent introducing bacteria from the vagina and anus into the urethra Avoid synthetic fabrics as these materials (eg, nylon, spandex) seal in moisture and create an environment conducive to bacterial proliferation; cotton underwear is recommended instead (Option F). Void after sexual intercourse to flush out bacteria that may have entered the urethra (Option E). (Options A and D) Avoid douching and using feminine perineal products (eg, deodorants, powders, sprays), as they can alter the vaginal pH and normal flora, increasing the risk for infection. Take showers instead of baths as bath products (eg, bubble bath, oils) and bacteria in bath water can irritate the urethra and increase the risk of infection. (Option C) Avoid spermicidal contraceptive jelly as it can suppress the production of protective vaginal flora. Discontinue diaphragm use temporarily (until symptoms subside and antibiotic course is completed); a diaphragm increases pressure on the urethra and bladder neck, which may inhibit complete bladder emptying. Educational objective: Interventions to help prevent recurrent UTIs in sexually active female clients include avoiding use of feminine perineal products, vaginal douches, and spermicidal contraceptive jelly. Protective factors include wearing cotton underwear, increasing water intake, and voiding immediately after sexual intercourse.

Question 11

The nurse provides post-procedure teaching for a female client who had a cystoscopy as an outpatient. Which client statement indicates the need for additional instruction?

Accepted Answer

11ecbb05_ca85_a779_b433_8deefe04ea1a_MD0009_00 A cystoscopy is a procedure that uses a flexible fiber-optic scope inserted through the urethra into the urinary bladder with the client in the lithotomy position. Complications associated with cystoscopy include urinary retention, hemorrhage, and infection. Therefore, clients are instructed to notify the health care provider (HCP) immediately if they have bright red blood when urinating, blood clots, inability to urinate, fever >100.4 F (38 C) and chills, or abdominal pain unrelieved by analgesia. These conditions necessitate evaluation by the HCP and may require antibiotic therapy or the insertion of a urinary catheter to irrigate the bladder, remove clots, or drain the bladder (Option D). (Options A and C) Pink-tinged urine, frequency, and dysuria are expected for up to 48 hours following a cystoscopy. Clients are instructed to increase fluids, drink 4-6 glasses of water daily to help dilute the urine, and avoid alcohol and caffeine for 24-48 hours as these can irritate the bladder. (Option B) Abdominal discomfort and bladder spasms may occur for up to 48 hours following the procedure. Clients are taught to take a mild analgesic (eg, acetaminophen, ibuprofen) and a warm tub/sitz bath (except with recurrent urinary tract infections) for pain relief. Educational objective: Clients can expect pink-tinged urine, frequency, dysuria, and abdominal discomfort for up to 48 hours after cystoscopy. They are instructed to increase fluid intake, avoid alcohol and caffeine, take a mild analgesic and tub/sitz bath to relieve discomfort, and notify the HCP immediately of inability to void, gross hematuria, blood clots, fever, chills, or severe pain.

Question 12

Which nursing instruction is the highest priority when teaching a 38-year-old female client newly diagnosed with stress incontinence?

Accepted Answer

The nursing care plan for a client experiencing stress incontinence includes pelvic floor exercises, bladder training, incontinence products, and lifestyle modifications. The highest priority for a client newly diagnosed with stress incontinence is preventing skin breakdown and urinary tract infections through bladder training. Teaching the client to empty the bladder every 2 hours when awake and every 4 hours at night reduces these risks (Option B). Pelvic floor exercises (eg, Kegel exercises), which strengthen the sphincter and structural supports of the bladder, are an essential part of the teaching plan but are not the priority for this client (Option A). It will take approximately 6 weeks for pelvic floor muscle strength to improve. Natural bladder irritants (eg, smoking, caffeine, alcohol) increase incontinence and should be eliminated but are not the priority in this client (Option C). Pessaries relieve minor pelvic organ prolapse and may be used in some clients when initial conservative measures fail. This client should receive initial instruction on the importance of emptying the bladder often (Option D). Educational objective: Nursing interventions related to stress incontinence include bladder training (eg, voiding every 2 hours), pelvic floor exercises (eg, Kegel exercises), lifestyle modifications (weight loss, reduction of dietary bladder irritants, smoking cessation), and incontinence products.

Question 13

Which health history information would be most important for the nurse to obtain when assessing a client with suspected bladder cancer who reports painless hematuria?

Accepted Answer

The tell-tale symptom of bladder cancer, seen in >75% of cases, is painless hematuria; the client will report seeing blood in the urine with no associated pain. As with many other types of cancer, the primary cause of bladder cancer is cigarette smoking or other tobacco use (Option C). Poorer outcomes are seen with increased length of time as a smoker and higher number of packs per day. (Option A) Clients who have family members with bladder cancer have an increased risk of developing bladder cancer themselves; however, the primary risk factor is tobacco use. (Option B) Occupational carcinogen exposure is the second most common risk factor. Occupational exposures include printing, iron and aluminum processing, industrial painting, metal work, machining, and mining. Clients are exposed to carcinogens through direct skin contact and inhalation (aerosols and vapors). (Option D) Consuming a high-fat diet and using artificial sweeteners are risk factors for developing bladder cancer, but they are not the primary cause. Educational objective: Painless hematuria is the most common presenting symptom of bladder cancer. Cigarette smoking or other tobacco use is the primary risk factor.

Question 14

A client has been given instructions about collecting a urine specimen to test creatinine clearance.  The client indicates correct understanding of the specimen collection procedure by making which statement?

Accepted Answer

Creatinine clearance is a measure of glomerular function and is a sensitive indicator of renal disease progression. A 24-hour urine collection is needed for the test. When the test begins, the first urine specimen is discarded and the time is noted. All other voided urine for the next 24 hours is collected in a container and kept cool. At the end of the 24 hours, the client should void one last time and add the specimen to the container. Blood is drawn to measure serum creatinine level in addition to urine creatinine. (Option A) An in-and-out catheter (straight catheter) is used for any test requiring a urine specimen when the client is unable to urinate or unable to follow the specimen collection procedure. A catheter is also used for a cystourethrogram or a residual urine test. (Option B) Clean catch or midstream urine samples are collected for urinalysis or urine culture and sensitivity testing. For a creatinine clearance test, all urine for the 24-hour period must be collected or the test must be started again. (Option D) The first AM void is preferable for a urinalysis or urine culture and sensitivity as an overnight specimen is more concentrated. Educational objective: Creatinine clearance is a measure of the glomerular filtration rate. The test requires a 24-hour urine specimen and a blood specimen. When the test begins, the first urine specimen is discarded and the time is noted.

Question 15

A client taking morphine sulfate for acute pain has not voided in 6 hours. The nurse suspects the client has developed urinary retention. What is the priority nursing intervention?

Accepted Answer

Opioids (eg, morphine sulfate), anticholinergic medications, and tricyclic antidepressants can cause urinary retention; they increase bladder sphincter tone and/or relax bladder muscle. The nurse should assess the client's suprapubic area to determine if the client has urinary retention. If the area is distended and dull to percussion, the nurse should proceed with interventions. (Option A) While asking if a bedpan is needed is an important nursing intervention, it does not aid in the assessment of urinary retention. (Option B) Gathering assessment data indicating the presence of urinary retention is necessary prior to other interventions. The nurse should assess for fluid intake after assessing bladder distension. (Option C) The client's skin turgor is assessed after the nurse checks for urinary retention and fluid intake. There is no need to assess skin turgor until other indicators of adequate fluid intake are reviewed. Educational objective: Assessing the client's suprapubic area is the priority nursing action when urinary retention is suspected. Interventions are performed after a problem is identified and its cause is determined. Urinary retention is an expected side effect of opioid medications.

Question 16

The charge nurse is making rounds and should immediately intervene when making which observation?

Accepted Answer

11ecbb05_ca80_c575_b433_fbeac951ce8d_MD0009_00 The flow of urine is dependent on gravity. In order to maintain gravity flow, the drainage bag should be hung below the level of the bladder. Impaired urine flow can lead to urinary retention and distension of the bladder. (Option A) Catheters placed in the kidney pelvis are irrigated using gentle pressure and small amounts of sterile saline solution (≤5 mL at one time) to avoid damaging renal tissues. (Option C) Securing an indwelling urinary catheter by taping it to a client's leg is acceptable to maintain gravity flow and prevent kinks and occlusions. Also, Velcro securement devices may be available at certain facilities. (Option D) Fluid intake of 3,000 mL per day should be encouraged in clients after surgery involving the urinary system. Increased fluid intake ensures the maintenance of a high urinary output, reducing the risk for infection. Dilute urine is less irritating to the skin surrounding the stoma site. Electrolyte reabsorption from reservoirs may increase risk for calculi. However, high fluid intake and urine output reduce this risk. Educational objective: The flow of urine is dependent on gravity. The drainage bag should be hung below the level of the bladder to maintain gravity flow.

Question 17

The nurse is conducting a pain assessment on a client with dysuria. Which pain description is most likely associated with pyelonephritis?

Accepted Answer

11ecbb05_ca80_0224_b433_d32b5c05c530_MD0009_00 Urinary tract infections (UTIs) can occur in the kidneys (pyelonephritis), bladder (cystitis), and/or urethra (urethritis). Pyelonephritis (inflammation of the kidney parenchyma) causes flank pain that is experienced in the back at the costovertebral angle (the angle between the lower ribs and adjacent vertebrae) and may spread toward the umbilicus. Cystitis alone does not cause nausea/vomiting or chills. Presence of these, fever, and signs and symptoms of a lower UTI (dysuria, urgency, and frequency) indicate pyelonephritis. (Option A) The client with a distended bladder experiences constant pain increased by any pressure over the bladder. Bladder distension is found through palpation (firmness, pain, urgency) and percussion (dullness) over the suprapubic area. (Option B) Bladder and urethral pain is usually dull and continuous and may be experienced as spasms. The detrusor muscle of the bladder may spasm if cystitis is present. (Option D) Renal colic pain (in response to renal calculi) is excruciating, sharp, and stabbing; the client would be tossing in the bed unable to find a comfortable position. Pain radiates down to the groin area as the stone travels down the ureter. Educational objective: Pain in pyelonephritis is dull, constant, and maximal at the costovertebral angle area. Pain from renal stones is excruciating, sharp, and often radiates toward the groin from the flank. Suprapubic pain indicates bladder distension or cystitis. Spasms can be seen with infection (cystitis) or manipulation of the bladder.

Question 18

The nurse is caring for a 78-year-old client with a urinary tract infection (UTI). Which assessment finding would be most concerning and require immediate follow-up by the nurse?

Accepted Answer

Confusion is a common clinical manifestation of urinary tract infections in the elderly but still should be cause for concern and requires follow-up to rule out other possible causes. Confusion is not a normal finding in the elderly adult client. Some causes of confusion in the elderly include dehydration, lack of blood flow to the brain (stroke), decreased ability to metabolize medications, and concurrent infections. (Option B) Presbyopia is the decrease in ability to see objects close up. This is common in clients over age 40. (Option C) The elderly tend to have a lower body temperature, so 100.2 F (37.8 C) is considered febrile. This elevation is probably a result of the UTI and the nurse should follow up after further assessing the confusion. (Option D) An elevated WBC count would be expected in the presence of a current infection. Educational objective: Confusion is a common clinical manifestation of UTI in the elderly; however, it is still a cause for concern and should be evaluated further by the nurse.

Question 19

The nurse is caring for a 72-year-old client with a history of renal calculi and diabetes mellitus who was admitted for acute pyelonephritis. The nurse assesses shaking chills, temperature of 101.2 F (38.4 C), and flank pain. Which of the following is the priority nursing intervention?

Accepted Answer

Acute pyelonephritis is an infection of the kidney usually caused by an extension of infection from the lower urinary tract (bladder). Chills and fever, vomiting, flank pain, and costovertebral tenderness are characteristic. Blood and urine cultures should be obtained prior to initiation of antibiotic therapy whenever possible to identify the causative microorganisms and determine the most effective antibiotics (Option D). Given this client's age and underlying diabetes, sepsis can occur quickly. Therefore, antibiotics should be given immediately after cultures are obtained (Option A). (Option B) The nurse should check the client's baseline renal function and complete blood count tests to compare subsequent findings. This is not the priority nursing intervention. (Option C) The client has a history of renal calculi. Straining all urine is not the priority nursing intervention. Educational objective: The priority of care for acute pyelonephritis is to obtain blood and urine cultures before initiating antibiotic therapy whenever possible.

Question 20

Place the nursing actions for performing a renal system physical assessment in the correct order. All options must be used.

Accepted Answer

Examination of the urinary system requires an abdominal assessment. Therefore, assessment techniques must be reordered to optimize the examination. The steps for a renal system assessment are: Empty the bladder to avoid discomfort during percussion and palpation and to provide a clean-catch sample (if prescribed) (Option A) Inspect the abdomen and lower back for color, contour, symmetry, distension, and movements (eg, visible peristalsis). Inspection is always done first during physical examination (Option D). The nurse should auscultate immediately after inspection as percussion or palpation may increase bowel motility and interfere with sound transmission during auscultation. Listen for renal artery bruits in the right and left upper abdominal quadrants (Option B). renal artery Percuss for kidney borders, costovertebral angle tenderness, and bladder distension. A dull percussion sound indicates solid structures or fluid-filled cavities (eg, distended bladder). Palpate for bladder distension, masses, and tenderness. A distended bladder may be palpated at any point from the symphysis pubis to the umbilicus and is felt as a firm, rounded organ. A normal kidney is not usually palpable; a palpable kidney may indicate hydronephrosis or polycystic kidney disease (Option E). Document all renal assessment findings immediately after the examination (Option C). Educational objective: Physical assessment of the renal system includes the techniques of inspection, auscultation, percussion, and palpation, in that order. Allow the client to empty the bladder before beginning the assessment and auscultate immediately after inspection as percussion or palpation may increase bowel motility and interfere with sound transmission during auscultation. Always document the findings.

Exam 1: Adult Health

The nurse is caring for a 68-year-old male client following a laparoscopic cholecystectomy 8 hours ago. The client has not urinated since surgery. Which would be the most appropriate initial intervention?

The nurse caring for multiple clients who underwent renal system diagnostic testing should report which post-procedure finding to the health care provider?

The nurse cares for a client scheduled for a percutaneous left kidney biopsy as an outpatient. Which intervention should the nurse include in the client's post-procedure care plan?

The nurse is caring for a client with an ileal conduit. While assisting the client in removing the external pouch, the nurse observes that the stoma appears bluish grey. What is the nurse's best action?

A client suffering from bladder prolapse and subsequent stress urinary incontinence has discussed treatment options with the health care provider (HCP) . The nurse evaluates that the client understands support pessary use when the client makes which statement?

The evening shift nurse reviews the preoperative checklist and latest serum laboratory values for an elderly client with a ruptured diverticulum who is scheduled for surgery in the early morning. Which laboratory value is most important for the nurse to report to the health care provider?

A client who was discharged following a prostatectomy performed 6 days ago calls the clinic and reports passing some small blood clots and experiencing a decreased urinary stream. What is the nurse's best response?

When a client diagnosed with acute urinary retention is emergently catheterized, the nurse should initially assess for which priority manifestation that may occur as a result of the catheterization?

The nurse gathers a health history from a 58-year-old male client with acute urinary retention. Which of the following questions should the nurse ask to aid in assessing for benign prostatic hyperplasia? Select all that apply.

A sexually active female client has had 3 urinary tract infections (UTIs) in 12 months. Which instructions should the nurse include in teaching the client how to prevent UTI recurrence? Select all that apply.

The nurse provides post-procedure teaching for a female client who had a cystoscopy as an outpatient. Which client statement indicates the need for additional instruction?

Which nursing instruction is the highest priority when teaching a 38-year-old female client newly diagnosed with stress incontinence?

Which health history information would be most important for the nurse to obtain when assessing a client with suspected bladder cancer who reports painless hematuria?

A client has been given instructions about collecting a urine specimen to test creatinine clearance. The client indicates correct understanding of the specimen collection procedure by making which statement?

A client taking morphine sulfate for acute pain has not voided in 6 hours. The nurse suspects the client has developed urinary retention. What is the priority nursing intervention?

The charge nurse is making rounds and should immediately intervene when making which observation?

The nurse is conducting a pain assessment on a client with dysuria. Which pain description is most likely associated with pyelonephritis?

The nurse is caring for a 78-year-old client with a urinary tract infection (UTI) . Which assessment finding would be most concerning and require immediate follow-up by the nurse?

The nurse is caring for a 72-year-old client with a history of renal calculi and diabetes mellitus who was admitted for acute pyelonephritis. The nurse assesses shaking chills, temperature of 101.2 F (38.4 C) , and flank pain. Which of the following is the priority nursing intervention?

Place the nursing actions for performing a renal system physical assessment in the correct order. All options must be used.