Individual Health Assessment (NURS 3013)/NURS3013 Final Exam question bank_ answered with rationales, 100% updated latest spring 26.

Individual Health Assessment (NURS 3013)/NURS3013 Final Exam question bank_ answered with rationales, 100% updated latest spring 26. 1. A 50-year-old client with cirrhosis of the liver is passive in his care and projects blame for his problem on others. What nursing interventions would help the client improve self-esteem? a. Encourage him to reminisce about his childhood. b. Help him to talk about his alcoholism. c. Involve the client in setting care goals. d. Discourage interaction with family at his home 2. The nursing diagnosis altered mental status related to profuse bleeding esophageal varices was entered on the care plan for a client with cirrhosis. The nurse should plan to a. Administer IV albumin three times a day. b. Monitor the alcohol and BUN levels. c. Restrict fluids and administer lactulose with neomycin. d. Prepare for the insertion of Blakemore Sengstaken tube and saline lavages. 3. A hospitalized client tells the nurse that a living will is being prepared by her lawyer and will be bringing the document to be signed. It will take two witnesses and the client asks the nurse to be a witness. What is the most appropriate response by the nurse to the client? a. “You will need to find a witness other than me.” b. “I will call the nurse supervisor to request assistance regarding your request for a witness.” c. “I will sign as a witness to your signature.” d. “Whoever is available at the time will sign as a witness.” 4. During the acute phase of hepatitis, the nurse would expect the client’s laboratory results to include: a. Decreased aspartate aminotransferase (AST) b. Decreased urinary urobilinogen c. Increased indirect serum bilirubin d. Increased alanine aminotransferase (ALT) 5. A client who has cirrhosis of the liver is scheduled for a paracentesis. Which statement made by the client will necessitate further teaching. a. “Once this is done, my abdomen will never be discented again.” b. “I will need to empty my bladder before the procedure.” c. “I know that the procedure will help me breathe better.” d. “The procedure can be done at the bedside.” 6. A client with cirrhosis has a PT of 35.4 seconds. Which of the nursing interventions should receive priority in the nursing care plan? a. Use the smallest gauge needle when giving injection b. Observe the skin and mucus membranes for rashes c. Check the urine for the presence of blood and albumin. d. Administer low dose vitamin K 7. A client who has adrenalectomy is receiving discharge instruction from the nurse. Which statement by the client reflects lack of understanding of her discharge instruction? (Select all that apply) a. “I will need to watch my salt intake.” b. I have to keep stress level down.” c. “I must wear an identification bracelet at all times.” d. “I will remain on the same dose of steroids at all times 8. Serologic test of a client reveals anti-HCV. The nurse recognizes that the client a. Has immunity to hepatitis C b. Has acute or chronic infection HCV c. Is susceptible to acquiring hepatitis C d. Indicates previous infection with hepatitis C 9. Serologic test of a client reveals anti-HCV. The nurse recognizes that the client a. Has immunity to Hepatitis C b. Has acute or chronic infection with HCV c. Is susceptible to acquiring Hepatitis C d. Indicates previous infection with Hepatitis C 10. A 40 - year old man has been diagnosed with metastatic brain cancer with poor prognosis. He plans an extensive trip around the country to visit family he has not seen in years and to vacation in places he has always wanted to visit. The nurse recognizes that the client is manifesting the psychological response of a. Restlessness b. Saying goodbye c. Unfinished business d. Altered decision making 11. A client is admitted with a diagnosis of Hepatitis B. Which of the following orders would the nurse question if prescribed? a. Administration of antiemetics for nausea and vomiting. b. A low-fat, high calorie diet c. Strict intake and output monitoring d. Instructions for the client to be up in a chair three times a day 12. The nurse is conducting a health promotion class with a group of clinic clients on pancreatitis. Which statements is correct about pancreatitis? a. Shock may occur because of hemorrhage into the pancreas b. The lungs are never involved in pancreatitis c. Bradycardia is always present in pancreatitis d. Ingestion of high doses of acetaminophen may cause pancreatitis 13. A client with end- stage liver disease is to undergo a liver transplant. She tells the nurse that she has a friend who had to have two kidney transplants because of rejection and that she hopes she does not have problems with rejection. The nurse's best response to the client is a. Perhaps your friend did not have a good tissue match with the frist kidney b. You are in good physical condition, and rejection wont be a problem for you c. The problem of rejection is not as common in liver transplants as in kidney transplants d. Rejection is always a possibility, but every day there are better immunosuppressive drugs. 14. The nurse would know that discharge teaching regarding diet was effective if the client with elevated ammonia levels selected a. Hamburger, fries, a strawberry shake b. Ham and beans, cornbread, and whole milk c. Scramble eggs, fish sticks, and 2% milk d. Macaroni with tomato sauce, broccoli, and applesauce 15 .The nurse is caring for a 75-year-old male client that is diagnosed with terminal illness. The nurse will question the goal for End of Life care that include: i. Help ensure a dignified death ii. Allow the family to leave until the client has died iii. Improve quality of remaining life iv. Comfort and supportive care during the dying process 1. The nurse is teaching a client with management of liver failure. Which of the following is not a component of quality nursing care for the client with liver failure? a. Hold the routine lactulose if the client has more than two bowel movements a day b. Avoid IM injections c. Limit visitors to avoid exposure to illness d. Measure the abdominal girth daily 2. When the nurse is caring for the client with pancreatic cancer, a major goal is a. Preventing narcotic addiction because of unrelenting pain b. Helping the client and family through the grieving process c. Maintaining adequate tissue perfusion to prevent skin breakdown d. Assessing for fluid and electrolyte imbalances caused by fluid loss into the peritoneal cavity 3. A client has early alcoholic cirrhosis diagnosed by a liver biopsy. When planning initial client teaching, the nurse will eliminate which information? (select all that apply) a. Vitamin B supplements b. Abstinence from alcohol c. Maintenance of a nutritious diet d. Long-term, low-dose corticosteroids 4. A client is jaundiced with severe ascites. The nurse expects the physician t o order which of these medications? a. Aspirin and lactulose b. Vancomycin and neomycin c. Albumin and Aldactone d. Vitamin K and Demerol 5. When teaching a client recovering from hepatitis B about management of the illness, the nurse determines that the client understands the teaching when the client says a. “When I have recovered from this infection, I should have lifelong immunity to the virus.” b. “When the jaundice is gone, I have recovered from the illness and the infection is cured.” c. “I should use condom during sexual activity for the rest of my life.” d. “I should not drink alcohol for at least two weeks.” 6. The nurse is caring for a client with a history of intravenous drugs abuse who is showing signs and symptoms of hepatitis. In planning care for this client, the nurse recognizes that the most common type of hepatitis contracted by IV drug users is which of the following? a. Hepatitis E b. Hepatitis C c. Hepatitis B d. Hepatitis A 7. A client with cirrhosis has a PT of 35.4 seconds. Which of the interventions should receive priority in the nursing care plan? a. Hemoccult test the stool and urine every 8 hours b. Observe the skin and mucous membranes for redness c. Check the urine for the presence of strong odor d. Administer low dose heparin therapy 1. An 80-year-old client has terminal cancer of the liver. The nurse is providing palliative care and the nurse understands that palliative care is the concept of client care that includes which of the following? (Select all that apply) a. Has a holistic approach to care and treatment b. Cannot start before hospice care c. Is limited to six months of care and treatment d. Provides symptom management when the client is not responding to curative treatment 2. During the acute phase of hepatitis, the nurse would expect the client’s laboratory results to include: a. Decreased aspartate aminotransferase (AST) b. Decreased urinary urobilinogen c. Increased indirect seru, bilirubin d. Increased alanine aminotransferase (ALT) 3. Clients with liver disease frequently exhibit fluid volume excess. The nurse knows that the best explanation for this alteration in fluid volume is a. Low levels of albumin and third-spacing of fluids (RIGHT ANSWER) b. Increased activation of the thirst mechanism c. Reduce portal vein pressure and venous return d. Increased intake of salty foods and fluids Lewis: Medical-Surgical Nursing, 7th Edition Test Bank Chapter 11: End-of-Life and Palliative Care MULTIPLE CHOICE 1. The nurse is caring for a patient who has 20-second periods of apnea followed by periods of deep and rapid breathing. The nurse documents this finding as a. death-rattle respirations. b. agonal breathing. c. apneustic breathing. d. Cheyne-Stokes respiration. Cheyne-Stokes respirations are characterized by periods of apnea alternating with deep and rapid breaths. The death rattle is caused by accumulation of mucus in the airways, causing wet-sounding respirations. Agonal breathing has a very slow and irregular rate and rhythm. Apneustic respirations are irregular and gasping. Cognitive Level: Application Text Reference: p. 152 Nursing Process: Assessment NCLEX: Physiological Integrity 2. A nursing student who is caring for a dying patient asks the nurse, “How will we know when the patient has died?” The nurse explains that the patient will be considered legally dead when a. the patient is flaccid and unresponsive. b. respiratory efforts cease and no apical pulse is audible. c. the patient is comatose, apneic, and without brainstem reflexes. d. CPR is ineffective in restoring heartbeat. The diagnosis of death is based on brain death; therefore, death has occurred when the patient has irreversible loss of all brain functions, including brainstem functions that control respirations and brainstem reflexes. The other descriptions describe other clinical manifestations associated with death but are insufficient to declare a patient legally dead. Cognitive Level: Comprehension Text Reference: p. 153 Nursing Process: Assessment NCLEX: Physiological Integrity 3. A patient near death is manifesting a decrease in all body system functions except for a heart rate of 124 and a respiratory rate of 28. The nurse explains to the family that these symptoms a. will continue to increase until death finally occurs. b. are a normal response before these functions decrease. c. may be associated with an improvement in the patient’s condition. d. indicate a reflex response to the slowing of other body systems. An increase in heart and respiratory rate may occur prior to the slowing of these functions in the dying patient. Heart and respiratory rate typically slow as the patient progresses further toward death. In a dying patient, high respiratory and pulse rates do not indicate improvement and it would be inappropriate for the nurse to indicate this to the family. The changes in pulse and respirations are not reflex responses. Cognitive Level: Comprehension Text Reference: p. 152 Nursing Process: Implementation NCLEX: Physiological Integrity 4. A patient who has been diagnosed with metastatic malignant melanoma and has a poor prognosis plans an extensive trip around the country “to finally see some of the places I’ve always wanted to visit and to see some family I haven’t seen in years.” The nurse recognizes that the patient is manifesting the psychosocial response of a. restlessness. b. saying goodbye. c. unfinished business. d. altered decision making. The patient’s statement indicates that there are some things that he or she would like to accomplish before dying. Restlessness is frequently a behavior associated with the patient’s inability to express needs, but this patient seems very clear in communicating needs. There is no clear indication that the patient is planning to saying good-bye to these relatives. The patient’s decision making is appropriate. Cognitive Level: Application Text Reference: p. 153 Nursing Process: Assessment NCLEX: Psychosocial Integrity 5. A family member of a patient who is being admitted with nausea tells the nurse that the patient was diagnosed 2 months ago with pancreatic cancer but has not kept appointments with the doctor and has continued daily activities unchanged from before the diagnosis. When assessing the patient, the nurse will expect that the patient a. will be very angry about the cancer diagnosis. b. will not mention anything about pancreatic cancer. c. may express despair about the cancer diagnosis. d. may ask about options for treatment of the cancer. The patient’s behaviors have been consistent with the denial, shock and disbelief, and avoidance stages described by various authors, and not mentioning cancer is consistent with this stage of grief. Anger, despair, and asking about treatment options are more consistent with other stages of grief such as anger, depression, and acceptance. Cognitive Level: Application Text Reference: p. 153 Nursing Process: Assessment NCLEX: Psychosocial Integrity 6. The wife of a patient with terminal lung cancer visits daily and cheerfully talks with the patient about vacation plans for the next year. When asked by the nurse how she is feeling, she says, “I’m busy at work, but otherwise things are fine.” An appropriate nursing diagnosis for the wife is a. caregiver role strain related to feeling overwhelmed. b. disabled family coping related to lack of grieving. c. anxiety related to complicated grieving process. d. hopelessness related to knowledge deficit about cancer. The wife’s behavior and statements indicate the presence of absent grief, which may lead to impaired adjustment as the patient progresses toward death. The wife does not appear to feel overwhelmed or anxious. The evidence does not support hopelessness as a problem for the patient’s wife. Cognitive Level: Application Text Reference: p. 154 Nursing Process: Diagnosis NCLEX: Psychosocial Integrity 7. As the nurse admits a patient with AIDS who has cryptococcal meningitis, the patient tells the nurse, “If my heart or breathing stop, I do not want to be resuscitated.” The nurse should a. document the request in the patient’s record and place a DNR notation in the care plan. b. ask the patient if these wishes have been discussed with the admitting health care provider. c. inform the patient that a notarized advance directive must be included in the record or resuscitation must be performed. d. advise the patient to designate a person to make health care decisions when the patient is not able to make them independently. A health care provider’s order should be written describing which actions nurses should take if the patient requires CPR, but the primary right to decide belongs to the patient or family. The nurse should document the patient’s request but does not have the authority to place the DNR order in the care plan. A notarized advance directive is not needed to establish the patient’s wishes. The patient may need a durable power of attorney for health care (or the equivalent), but this does not address the patient’s current concern with possible resuscitation. Cognitive Level: Application Text Reference: pp. 155-156 Nursing Process: Implementation NCLEX: Safe and Effective Care Environment 8. A patient who is very close to death is very restless and repeats, “I am not ready to die.” The most appropriate intervention by the nurse is to a. call the hospital chaplain to come and visit or pray with the patient. b. sit at the bedside and ask if there is anything the patient needs. c. inform the patient that everything possible is being done to delay death. d. ask the patient what can be done to assist with the acceptance of death. Staying at the bedside and listening allows the patient to discuss any unresolved issues that might be concerning him or her. Asking the patient’s own spiritual advisor to visit is appropriate, but the hospital chaplain might not be appropriate to meet the patient’s needs. Telling the patient that everything is being done or asking the patient how the nurse can help with the acceptance of death may not address the patient’s needs for psychosocial support. Cognitive Level: Application Text Reference: pp. 159-160 Nursing Process: Implementation NCLEX: Psychosocial Integrity 9. Which of these patients is most appropriate for the nurse to refer to hospice care? a. A 28-year-old with AIDS-related dementia who needs palliative care and pain management b. A 56-year-old with advanced liver failure whose family members can no longer care for him or her at home c. 60-year-old with lymphoma whose children are unable to discuss issues related to dying d. A 72-year-old with chronic severe pain as a result of spinal arthritis and vertebral collapse Hospice is designed to provide palliative care such as symptom management and pain control for patients at the end of life. Patients who require more care than the family can provide, whose families are unable to discuss important issues related to dying, or who have severe pain are candidates for other nursing services but are not appropriate hospice patients. Cognitive Level: Application Text Reference: pp. 156-157 Nursing Process: Planning NCLEX: Safe and Effective Care Environment 10. A patient in a hospice program is experiencing continuous, increasing amounts of pain. The nurse caring for the patient plans the scheduling of opioid pain medications to provide a. prn doses of medication whenever the patient requests. b. around-the-clock routine administration of analgesics. c. enough pain medication to keep the patient sedated and unaware of stimuli. d. analgesic doses that provide pain control without decreasing respiratory rate. The principles of beneficence and nonmaleficence indicate that the goal of pain management in a terminally ill patient is adequate pain relief even if the effect of pain medications could hasten death. Administration of analgesics on a prn basis will not provide the consistent level of analgesia the patient needs. Patients usually do not require so much pain medication that they are oversedated and unaware of stimuli. Adequate pain relief may require a dosage that will result in a decrease in respiratory rate. Cognitive Level: Application Text Reference: p. 161 Nursing Process: Planning NCLEX: Safe and Effective Care Environment 11. When caring for a patient with lung cancer in a home hospice program, it is important for the nurse to a. accomplish a thorough head-to-toe assessment at least weekly. b. educate the patient about the purpose of chemotherapy and radiation. c. complete a detailed intake assessment, including cancer risk factors. d. encourage the patient to discuss past life events and their meaning. The role of the hospice nurse includes assisting the patient with the important end-of life task of finding meaning in the patient’s life. The assessment is generally limited to essential data and a thorough weekly head-to-toe assessment; therefore, a detailed intake assessment is not needed and may tire the patient unnecessarily. Patients admitted to hospice forego curative treatments such as chemotherapy and radiation for lung cancer. Cognitive Level: Application Text Reference: pp. 159-160 Nursing Process: Implementation NCLEX: Psychosocial Integrity 12. A hospice nurse who has become very close to a terminally ill patient and family is present in the home when the patient dies. The family members are crying softly, and the nurse also feels like crying. The nurse recognizes that a. it is acceptable and healthy to cry with the family during this phase of the grief process. b. personal expression of sorrow and loss is appropriate to share with peers rather than burdening the patient’s family. c. it would be unprofessional to cry at this time when the family’s feelings need to be addressed. d. the family should be allowed to grieve together at this time and the nurse’s presence will be felt as invasive to the family. It is appropriate for the nurse to cry and express sadness in other ways when a patient dies, and the family is likely to feel that this is therapeutic. It is no longer considered unprofessional to express grief openly to patients and families. In addition, appropriately expressed grief will not be considered a burden or invasive to the family members. Cognitive Level: Application Text Reference: p. 163 Nursing Process: Implementation NCLEX: Safe and Effective Care Environment 13. A patient who has a regularly scheduled annual physical examination tells the nurse, “My mother died 6 months ago and I just can’t seem to get over it. I still think about her every day.” Which nursing diagnosis is most appropriate for this patient? a. Complicated grieving related to unresolved issues b. Chronic sorrow related to ongoing distress about loss of mother c. Risk-prone health behavior related to inability to resolve grief d. Anxiety related to lack of knowledge about normal grieving The patient should be reassured that grieving activities such as frequent thoughts about the deceased are considered normal during the first year after a death. The other nursing diagnoses imply that the patient’s grief is unusual or pathologic, which is not the case. Cognitive Level: Application Text Reference: pp. 154, 163 Nursing Process: Diagnosis NCLEX: Psychosocial Integrity 14. The family member of a dying patient tells the nurse, “I think mother needs an antidepressant. She has always been so outgoing, but now she seems really withdrawn and disinterested in life.” Which response by the nurse is most appropriate? a. “It is likely that she is depressed, so I will ask the doctor for an antidepressant order.” b. “Withdrawal may sometimes be a normal response when preparing to leave life.” c. “It will be important for you to stimulate your mother as she gets closer to dying.” d. “Your mother is becoming tired, and you may need to cut back your visits for now.” Withdrawal is a normal psychosocial response to approaching death. Withdrawal does not indicate depression, and antidepressants are not usually indicated. Stimulation will tire the patient and is not an appropriate response to withdrawal in this circumstance. Visitors are encouraged to be “present” with the patient, talking softly and making physical contact in a way that does not demand a response from the patient. Cognitive Level: Application Text Reference: pp. 153, 160 Nursing Process: Implementation NCLEX: Psychosocial Integrity Lewis: Medical-Surgical Nursing, 7th Edition Lewis: Medical-Surgical Nursing, 7th Edition Test Bank Chapter 45: Nursing Assessment: Urinary System MULTIPLE CHOICE 1. When reading a patient’s chart, the nurse notes that the patient has had dysuria. To assess whether there is any improvement, which question will the nurse ask? a. “Do you have any blood in your urine?” b. “Do you have to get up at night to urinate?” c. “Do you have any pain when you urinate?” d. “Do you have to urinate very frequently?” Dysuria is painful urination. The alternate responses are used to assess other urinary tract symptoms: hematuria, nocturia, and frequency. Cognitive Level: Application Text Reference: pp. 1143, 1145 Nursing Process: Assessment NCLEX: Physiological Integrity 2. When admitting a patient who has a history of paraplegia as a result of a spinal cord injury, the nurse will plan to a. check the patient for urinary incontinence every 2 hours to maintain skin integrity. b. assist the patient to the toilet on a scheduled basis to help ensure bladder emptying. c. use intermittent catheterization on a regular schedule to avoid the risk of infection. d. ask the patient about the usual urinary pattern and measures used for bladder control. Before planning any interventions, the nurse should complete the assessment and determine the patient’s normal bladder pattern and the usual measures used by the patient at home. All the other responses may be appropriate, but until the assessment is complete, an individualized plan for the patient cannot be developed. Cognitive Level: Application Text Reference: pp. Nursing Process: Planning NCLEX: Physiological Integrity 3. A patient’s urine dipstick indicates a large amount of protein in the urine. The next action by the nurse should be to a. check which medications the patient is currently taking. b. ask the patient about any family history of chronic renal failure. c. send a urine specimen to the laboratory to test for ketones and glucose. d. obtain a clean-catch urine for culture and sensitivity testing. Normally the urinalysis will show zero to trace amounts of protein, but some medications may give false-positive readings. The other actions by the nurse may be appropriate, but checking for medications that may affect the dipstick accuracy should be done first. Cognitive Level: Application Text Reference: p. 1146 Nursing Process: Assessment NCLEX: Physiological Integrity 4. A creatinine clearance test is ordered for a hospitalized patient with possible renal insufficiency. Which equipment will the nurse need to obtain? a. Foley catheter and drainage bag b. Towelettes for perineal cleaning c. Basin of ice d. Sterile specimen cup Creatinine clearance testing involves a 24-hour urine specimen collection. The urine should be refrigerated or cooled, or a preservative should be used. Catheterization, cleaning of the perineum with antiseptic towelettes, and a sterile specimen cup are not needed for this test. Cognitive Level: Application Text Reference: p. 1146 Nursing Process: Implementation NCLEX: Physiological Integrity 5. A 20-year-old patient who is employed as a hairdresser and has a 10 pack-year history of cigarette smoking is scheduled for an annual physical examination. The nurse will plan to teach the patient about the increased risk for a. bladder cancer. b. renal failure. c. pyelonephritis. d. kidney stones. Exposure to the chemicals involved in when working as a hairdresser and smoking both increase the risk of bladder cancer, and the nurse should assess whether the patient understands this risk. The patient is not at increased risk for renal failure, pyelonephritis, or kidney stones. Cognitive Level: Application Text Reference: p. 1142 Nursing Process: Planning NCLEX: Physiological Integrity 6. During assessment of a patient with a possible renal insufficiency, which of these medications taken by the patient at home will be of most concern to the nurse? a. Warfarin (Coumadin) b. Folic acid (vitamin B9) c. Ibuprofen (Motrin) d. Penicillin (Bicillin LA) The nonsteroidal antiinflammatory medications (NSAIDs) are nephrotoxic and should be avoided in patients with renal insufficiency. The nurse should also ask about reasons the patient is taking the other medications, but the medication of most concern is the ibuprofen. Cognitive Level: Application Text Reference: p. 1142 Nursing Process: Assessment NCLEX: Physiological Integrity 7. When the nurse is planning care for an 82-year-old man, an appropriate intervention based on an understanding of age-related changes of the urinary system is for the nurse to a. limit fluid intake to no more than 1500 ml/day. b. leave a light on in the bathroom at night. c. ask the patient to use a urinal so that all urine can be measured. d. pad the patient’s bed to accommodate overflow incontinence. Because of a decrease in the ability of the kidney to concentrate urine, nocturia is common in older patients. Fluids should be encouraged because dehydration is more common in older patients. The information in the question does not indicate that measurement of the patient’s output is necessary or that the patient has overflow incontinence. Cognitive Level: Application Text Reference: pp. 1141, 1144 Nursing Process: Planning NCLEX: Physiological Integrity 8. While assessing a patient’s urinary system, the nurse cannot palpate either kidney. Which action should the nurse take next? a. Ask the patient about any history of recent sore throat. b. Obtain a urine specimen to check for hematuria. c. Ask the health care provider about scheduling a renal ultrasound. d. Document the information on the assessment form. The kidneys are protected by the abdominal organs, ribs, and muscles of the back and may not be palpable under normal circumstances, so no action except to document the assessment information is needed. Asking about a recent sore throat, checking for hematuria, or obtaining a renal ultrasound may be appropriate when assessing for renal problems for some patients, but there is nothing in the stem to indicate that they are appropriate for this patient. Cognitive Level: Application Text Reference: p. 1144 Nursing Process: Assessment NCLEX: Physiological Integrity 9. How will the nurse assess the flank area for tenderness? a. Percuss the area between the iliac crest and ribs along the midaxillary line. b. Palpate along both sides of the lumbar vertebral column. c. Place one hand flat at the costovertebral angle (CVA) and strike it with the other fist. d. Push gently into the two lowest intercostal spaces. Checking for flank pain is best performed by percussion of the CVA and asking about pain. The other techniques would not assess for flank pain. Cognitive Level: Comprehension Text Reference: pp. Nursing Process: Assessment NCLEX: Physiological Integrity 10. The result of a patient’s creatinine clearance test is 60 ml/min. The nurse equates this finding to a glomerular filtration rate (GFR) of ml/min. a. 30 b. 60 c. 120 d. 240 The creatinine clearance approximates the GFR. The other responses are not accurate. Cognitive Level: Comprehension Text Reference: p. 1146 Nursing Process: Assessment NCLEX: Physiological Integrity 11. The nurse uses auscultation during assessment of the urinary system to a. determine the position of the kidneys. b. assess for bladder distension. c. check for ureteral peristalsis. d. identify renal artery or aortic bruits. The presence of a bruit may indicate problems such as renal artery tortuosity or abdominal aortic aneurysm. Auscultation would not be helpful in assessing for the other listed urinary tract information. Cognitive Level: Comprehension Text Reference: p. 1145 Nursing Process: Assessment NCLEX: Physiological Integrity 12. When reviewing the results of a patient’s urinalysis, which information indicates that the nurse should notify the health care provider? a. pH 6.2 b. Protein: 6 mg/dl c. WBC: 20–26/hpf d. Specific gravity: 1.021 The increased number of white blood cells (WBCs) indicates the presence of urinary tract infection or inflammation. The other findings are normal. Cognitive Level: Comprehension Text Reference: p. 1152 Nursing Process: Assessment NCLEX: Physiological Integrity 13. A patient with a possible renal cell tumor who is scheduled for an intravenous pyelogram (IVP) and computed tomography (CT) scanning of the abdomen gives the nurse all the following data. Which information has the most immediate implications for the patient’s care? a. The patient has not had anything to eat or drink for 8 hours. b. The patient used a bisacodyl (Dulcolax) tablet the previous night. c. The patient describes allergies to shellfish and penicillin. d. The patient complains of costovertebral angle (CVA) tenderness. Iodine-based contrast dye is used during IVP and for many CT scans. The nurse will need to notify the health care provider before the procedures so that the patient can receive medications such as antihistamines or corticosteroids before the procedures are started. The other information is also important to note and document but does not have immediate implications for the patient’s care during the procedures. Cognitive Level: Application Text Reference: pp. Nursing Process: Assessment NCLEX: Physiological Integrity 14. When teaching a patient scheduled for a cystogram via a cystoscope about the procedure, the nurse tells the patient, a. “Your doctor will place a catheter into an artery in your groin and inject a dye that will visualize the blood supply to the kidneys.” b. “Your doctor will inject a radioactive solution into a vein in your arm and the distribution of the isotope in your kidneys and bladder will be checked.” c. “Your doctor will insert a lighted tube into the bladder through your urethra, inspect the bladder, and instill a dye that will outline your bladder on x-ray.” d. “Your doctor will insert a lighted tube into the bladder, and little catheters will be inserted through the tube into your kidney.” In a cystoscope and cystogram procedure, a cystoscope is inserted into the bladder for direct visualization, and then contrast solution is injected through the scope so that x-rays can be taken. The response beginning, “Your doctor will place a catheter” describes a renal arteriogram procedure. The response beginning, “Your doctor will inject a radioactive solution” describes an IVP. And the response beginning, “Your doctor will insert a lighted tube into the bladder, and little catheters will be inserted” describes a retrograde pyelogram. Cognitive Level: Application Text Reference: pp. Nursing Process: Implementation NCLEX: Physiological Integrity 15. The nurse informs the patient undergoing cystoscopy that following the procedure, the patient a. should ask for the ordered narcotics as necessary for pain. b. will be NPO for 8 hours to prevent nausea and vomiting. c. may experience blood-tinged urine and urinary frequency. d. is expected to be on strict bed rest for about 4 to 6 hours. Pink-tinged urine and urinary frequency are expected after cystoscopy. Burning on urination is common, but pain that requires narcotics for relief is not expected. A good fluid intake is encouraged after this procedure. Bed rest is not required following cystoscopy. Cognitive Level: Application Text Reference: p. 1149 Nursing Process: Implementation NCLEX: Physiological Integrity 16. A patient with an elevated blood urea nitrogen (BUN) and serum creatinine is scheduled for a renal arteriogram. The nurse should question an order from radiology for bowel preparation with the use of a. senna/docusate (Sennakot-S). b. Fleet enema. c. tap-water enema. d. bisacodyl (Dulcolax) tablets. High-phosphate enemas, such as Fleet enemas, should be avoided in patients with renal insufficiency (as evidenced by an increased BUN and creatinine). The other medications for bowel evacuation are more appropriate. Cognitive Level: Application Text Reference: p. 1149 Nursing Process: Implementation NCLEX: Physiological Integrity 17. The health care provider orders a clean-catch urine specimen for culture and sensitivity testing for a patient with a suspected urinary tract infection (UTI). To obtain the specimen, the nurse will plan to a. teach the patient to clean the urethral area, void a small amount into the toilet, then void into a sterile specimen cup. b. insert a short, small “mini” catheter attached to a collecting container into the urethra and bladder to obtain the specimen. c. clean the area around the meatus with a povidone-iodine (Betadine) swab, and then have the patient void into a sterile container. d. have the patient empty the bladder completely, and then obtain the next urine specimen that the patient is able to void. This answer describes the technique for obtaining a clean-catch specimen. The answer beginning, “insert a short, small, ‘mini’ catheter attached to a collecting container” describes a technique that would result in a sterile specimen, but a health care provider’s order for a catheterized specimen would be required. Using Betadine before obtaining the specimen is not necessary and might result in suppressing the growth of some bacteria. And the technique described in the answer beginning “have the patient empty the bladder completely” would not result in a sterile specimen. Cognitive Level: Application Text Reference: p. 1146 Nursing Process: Implementation NCLEX: Physiological Integrity 18. A patient who had a cystoscopy the previous day calls the urology clinic and gives the nurse all the following information. Which statement by the patient should be reported immediately to the health care provider? a. “My urine still looks pink.” b. “I did not sleep well last night.” c. “I have a temperature of 101.” d. “My IV site is still bruised.” The patient’s elevated temperature may indicate a bladder infection, a possible complication of cystoscopy. The health care provider should be notified so that antibiotic therapy can be started. Pink-tinged urine is expected after a cystoscopy. The insomnia and bruising should be discussed further with the patient but do not indicate a need to notify the health care provider. Cognitive Level: Application Text Reference: p. 1149 Nursing Process: Assessment NCLEX: Physiological Integrity 19. A hospitalized patient with renal insufficiency is scheduled to have an IVP. Which nursing action will be needed during this procedure? a. Assist with monitoring for conscious sedation. b. Insert a large size urinary catheter prior to the IVP. c. Monitor the urine output after the procedure. d. Give oral contrast solution before the procedure. Patients with impaired renal function are at risk for decreased renal function after IVP because the contrast medium used is nephrotoxic, so the nurse should monitor the patient’s urine output. Conscious sedation and retention catheterization are not required for the procedure. The contrast medium is given intravenously, not orally. Cognitive Level: Application Text Reference: p. 1147 Nursing Process: Implementation NCLEX: Physiological Integrity 20. Following an intravenous pyelogram (IVP), all of these assessment data are obtained. Which one requires immediate action by the nurse? a. The urine output is 400 ml in the first 2 hours. b. The patient complains of a dry mouth. c. The heart rate is 58 beats/min. d. The respiratory rate is 38 breaths/min. The increased respiratory rate indicates that the patient may be experiencing an allergic reaction to the contrast medium used during the procedure. The nurse should immediately assess the patient’s oxygen saturation and breath sounds. The other data are not unusual findings following an IVP. Cognitive Level: Application Text Reference: p. 1147 Nursing Process: Assessment NCLEX: Physiological Integrity 21. A patient with diabetic nephropathy is admitted for a right renal biopsy. Immediately after the biopsy, which of these is an essential nursing action? a. Check blood glucose to assess for hyperglycemia or hypoglycemia. b. Obtain a urine specimen to check for hematuria. c. Monitor the BUN and creatinine to assess renal function. d. Place the patient on the right side to put pressure on the site. The patient is placed in a supine position to put pressure on the biopsy side and decrease the risk for bleeding. The blood glucose and BUN/creatinine will not be affected by the biopsy. Hematuria is a common finding immediately after a renal biopsy. Cognitive Level: Application Text Reference: p. 1149 Nursing Process: Implementation NCLEX: Physiological Integrity Lewis: Medical-Surgical Nursing, 7th Edition Test Bank Chapter 46: Nursing Management: Renal and Urologic Problems MULTIPLE CHOICE 1. When assessing the patient who has a lower urinary tract infection (UTI), the nurse will initially ask about a. flank pain. b. pain with urination. c. poor urine output. d. nausea. 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. Cognitive Level: Application Text Reference: p. 1157 Nursing Process: Assessment NCLEX: Physiological Integrity 2. Trimethoprim and sulfamethoxazole (Bactrim) BID for 7 days is ordered for a patient who has a recurrent relapse of an Escherichia coli UTI. The nurse instructs the patient to a. take the antibiotic for the full 7 days, even if symptoms improve in a few days. b. return to the clinic in 3 days so that a urine culture can be done to evaluate the effectiveness of the drug. c. increase the effectiveness of the drug by taking it with cranberry juice to acidify the urine. d. take two of the pills a day for 5 days, and reserve the rest of the pills to take if the symptoms reappear. Although an initial infection may be treated with a shorter course of antibiotics, the patient with a recurrent infection should take the antibiotic for 7 days. Success of treatment is evaluated by resolution of symptoms rather than by a repeat culture. Acidifying the urine when a patient is taking sulfa antibiotics may lead to stone formation. The patient is instructed to take all the antibiotics. Cognitive Level: Application Text Reference: p. 1157 Nursing Process: Implementation NCLEX: Physiological Integrity 3. The nurse determines that instruction regarding prevention of future UTIs for a patient with cystitis has been effective when the patient states, a. “I will empty my bladder every 3 to 4 hours during the day.” b. “I can use vaginal sprays to reduce bacteria.” c. “I will wash with soap and water before sexual intercourse.” d. “I will drink a quart of water or other fluids every day.” Voiding every 3 to 4 hours is recommended to prevent UTIs. Use of vaginal sprays is discouraged. The bladder should be emptied before and after intercourse, but cleaning with soap and water is not necessary. A quart of fluids is insufficient to provide adequate urine output to decrease risk for UTI. Cognitive Level: Application Text Reference: p. 1161 Nursing Process: Evaluation NCLEX: Health Promotion and Maintenance 4. To relieve the symptoms of a lower UTI for which the patient is taking prescribed antibiotics, the nurse suggests that the patient use the OTC urinary analgesic phenazopyridine (Pyridium) but cautions the patient that this preparation a. contains methylene blue, which turns the urine blue or green. b. should be taken on an empty stomach for maximum effect. c. causes the urine to turn reddish orange and can stain underclothing. d. frequently causes allergic reactions and should be stopped if a rash occurs. Patients should be taught that Pyridium will color the urine deep orange and stain underclothing. Urised may turn the urine blue or green. The medication can cause gastrointestinal distress and should be taken with food. Although an allergic reaction may occur, this is not common. Cognitive Level: Comprehension Text Reference: p. 1158 Nursing Process: Implementation NCLEX: Physiological Integrity 5. A 34-year-old patient with diabetes mellitus is hospitalized with fever, anorexia, and confusion. The health care provider suspects acute pyelonephritis when the urinalysis reveals bacteriuria. An appropriate collaborative problem identified by the nurse for the patient is potential complication a. hydronephrosis. b. urosepsis. c. acute renal failure. d. chronic pyelonephritis. Infection can easily spread from the kidney to the circulation, causing urosepsis. A patient with a urinary tract obstruction will be at risk for hydronephrosis. Acute renal failure is not a common complication of acute pyelonephritis unless urosepsis and septic shock develop. Chronic pyelonephritis may occur after recurrent upper UTIs. Cognitive Level: Application Text Reference: p. 1161 Nursing Process: Diagnosis NCLEX: Physiological Integrity 6. A 72-year-old patient with benign prostatic hyperplasia and a history of frequent UTIs is admitted to the hospital with chills, fever, and nausea and vomiting. To determine whether the patient has an upper UTI, the nurse will assess for a. suprapubic pain. b. foul-smelling urine. c. bladder distension. d. costovertebral angle (CVA) tenderness. CVA 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. Cognitive Level: Application Text Reference: p. 1161 Nursing Process: Assessment NCLEX: Physiological Integrity 7. 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 should call the doctor about increased bladder pain or odorous urine.” d. “I will buy some calcium glycerophosphate (Prelief) at the pharmacy.” High-potency multiple vitamins may irritate the bladder and increase symptoms. The other patient statements indicate good understanding of the teaching. Cognitive Level: Application Text Reference: p. 1164 Nursing Process: Evaluation NCLEX: Physiological Integrity 8. When admitting a patient with acute glomerulonephritis, the nurse will ask the patient about a. history of high blood pressure. b. frequency of UTIs. c. recent sore throat and fever. d. family history of kidney disease. Acute glomerulonephritis frequently occurs after a streptococcal infection such as strep throat. It is not caused by hypertension, UTI, or related to family history. Cognitive Level: Application Text Reference: p. 1165 Nursing Process: Assessment NCLEX: Physiological Integrity 9. The nurse establishes a nursing diagnosis of excess fluid volume related to inflammation at the glomerular basement membrane in a patient with acute glomerulonephritis. To best evaluate whether the problem identified in the nursing diagnosis has resolved, the nurse will monitor for a. proteinuria. b. elevated creatinine. c. periorbital edema. d. hematuria. Resolution of the excess fluid volume is best evaluated by changes in edema. The other data may indicate whether the glomerulonephritis is resolving but do not provide data about fluid volume. Cognitive Level: Application Text Reference: p. 1165 Nursing Process: Evaluation NCLEX: Physiological Integrity 10. A patient with nephrotic syndrome develops flank pain. The nurse will anticipate treatment with a. antibiotics. b. antihypertensives. c. anticoagulants. d. corticosteroids. 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. Cognitive Level: Application Text Reference: p. 1175 Nursing Process: Planning NCLEX: Physiological Integrity 11. 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. Fluid-volume excess related to low serum protein levels b. Altered nutrition: less than required related to protein restriction c. Activity intolerance related to increased weight and fatigue d. Disturbed body image related to peripheral edema and ascites The patient has massive edema, so the priority problem at this time is the excess of fluid volume. The other nursing diagnoses are also appropriate, but the focus of nursing care should be resolution of the edema and ascites. Cognitive Level: Application Text Reference: pp. Nursing Process: Diagnosis NCLEX: Physiological Integrity 12. A patient is admitted to the hospital with nephrotic syndrome after taking an OTC nonsteroidal antiinflammatory drug (NSAID) a week earlier. Which assessment data will the nurse expect to find related to this illness? a. Low blood pressure b. Recent weight gain c. Poor skin turgor d. High urine ketones The patient with a rapid-onset nephrotic syndrome will have rapid 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. Cognitive Level: Application Text Reference: p. 1167 Nursing Process: Assessment NCLEX: Physiological Integrity 13. A 98-year-old patient with benign prostatic hyperplasia has a markedly distended bladder and is agitated and confused. All the following orders are received from the emergency department health care provider. Which order should the nurse act on first? a. Draw blood for blood urea nitrogen (BUN) and creatinine. b. Administer lorazepam (Ativan) 0.5 mg. c. Insert 16 French retention catheter. d. Schedule for IVP. The patient’s history and clinical manifestations are consistent with acute urinary retention, and the priority action is to relieve the retention by catheterization. The BUN and creatinine measurements can be obtained after the catheter is inserted. The patient’s agitation may resolve 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. Cognitive Level: Application Text Reference: p. 1185 Nursing Process: Implementation NCLEX: Physiological Integrity 14. A patient with a history of renal calculi is hospitalized with gross hematuria and severe colicky left flank pain that radiates to his left testicle. In planning care for the patient, the nurse gives the highest priority to the nursing diagnosis of a. acute pain related to irritation by the stone. b. deficient fluid volume related to inadequate intake. c. risk for infection related to urinary system damage. d. risk for nausea related to pain and renal colic. Although all the diagnoses are appropriate, the initial nursing actions should focus on relief of the acute pain. Cognitive Level: Application Text Reference: p. 1173 Nursing Process: Diagnosis NCLEX: Physiological Integrity 15. The nurse instructs a patient seen in the outpatient clinic with symptoms of renal calculi to strain all urine and to a. report the pain level when the stone passed. b. collect the stone and bring it to the clinic. c. record the time that the stone passed. d. save a urine specimen to check for blood. The patient should save the stone for analysis of the stone composition, which will help in determining treatment. Reporting the pain level and recording the time the stone passed are not essential. Hematuria is common with urinary calculi, so it is not necessary to test the urine for blood. Cognitive Level: Application Text Reference: p. 1173 Nursing Process: Implementation NCLEX: Physiological Integrity 16. A patient with a confirmed urinary stone in the proximal left ureter undergoes extracorporeal shock-wave lithotripsy. Which information is most important for the nurse to collect after lithotripsy? a. Urine output b. Pain level c. Appearance of the site d. Patient temperature Because lithotripsy breaks the stone into small sand, which could cause obstruction, it is important to monitor the urine output. The patient may have pain as the stones pass and bruising at the site, but these are not unexpected. Extracorporeal shock wave lithotripsy (ESWL) is not associated with a risk for infection. Cognitive Level: Application Text Reference: p. 1172 Nursing Process: Assessment NCLEX: Physiological Integrity 17. The composition of a patient’s renal calculus is identified as uric acid. To prevent recurrence of stones, the nurse teaches the patient to avoid a. spinach, chocolate, and tomatoes. b. organ meats and fish with fine bones. c. milk and dairy products. d. legumes and dried fruits. 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. Cognitive Level: Application Text Reference: pp. Nursing Process: Implementation NCLEX: Health Promotion and Maintenance 18. To prevent the recurrence of renal calculi, the nurse teaches the patient to a. avoid all sources of dietary calcium. b. drink diuretic fluids such as coffee. c. drink 2000 to 3000 ml of fluid a day. d. use a filter to strain all urine. A fluid intake of 2000 to 3000 ml daily is recommended help flush out minerals before stones can form. Patients are not advised to avoid all calcium-containing foods and a high calcium intake may decrease the incidence of some types of stones. 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. Cognitive Level: Application Text Reference: p. 1172 Nursing Process: Implementation NCLEX: Physiological Integrity 19. In planning teaching for a patient with benign nephrosclerosis, the nurse should include instructions regarding a. measuring daily intake and output amounts. b. obtaining and documenting daily weights. c. monitoring and recording blood pressure. d. preventing bleeding caused by anticoagulants. 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. Cognitive Level: Application Text Reference: p. 1175 Nursing Process: Planning NCLEX: Health Promotion and Maintenance 20. 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. Differences between hemodialysis and peritoneal dialysis b. Complications of renal transplantation c. Methods for treating chronic and severe pain d. Importance of genetic counseling 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. Cognitive Level: Application Text Reference: p. 1176 Nursing Process: Implementation NCLEX: Health Promotion and Maintenance 21. When assessing a patient who complains of a feeling of incomplete bladder emptying and a split, spraying urine stream, the nurse asks about a history of a. recurrent renal calculi. b. kidney trauma. c. bladder infection. d. gonococcal urethritis. The patient’s clinical manifestations are consistent with urethral strictures, a possible complication of gonococcal urethritis. These symptoms are not consistent with renal calculi, kidney trauma, or bladder infection. Cognitive Level: Application Text Reference: p. 1174 Nursing Process: Assessment NCLEX: Physiological Integrity 22. When obtaining the health history for a 30-year-old patient who smokes two packs of cigarettes daily, the nurse will plan to do teaching about the increased risk for a. interstitial cystitis. b. UTI. c. kidney stones. d. bladder cancer. Cigarette smoking is a risk factor for bladder cancer. The patient’s risk for developing interstitial cystitis, UTI, or kidney stones will not be reduced by quitting smoking. Cognitive Level: Application Text Reference: p. 1178 Nursing Process: Planning NCLEX: Health Promotion and Maintenance 23. Following an open-loop resection and fulguration of the bladder, a patient is unable to void. Which nursing action should be implemented? a. Assist the patient to take a 15-minute sitz bath. b. Encourage the patient to drink several glasses of water. c. Teach the patient how to do isometric perineal exercises. d. Insert a straight catheter and drain the bladder. Sitz baths will relax the perineal muscles and promote voiding. Although the patient should be encouraged to drink fluids, this would not be appropriate when the patient is experiencing retention. Kegel exercises are helpful in the prevention of incontinence. Catheter insertion increases the risk for infection. Cognitive Level: Application Text Reference: p. 1179 Nursing Process: Implementation NCLEX: Physiological Integrity 24. A 78-year-old patient is admitted to the hospital with dehydration and electrolyte imbalance. The patient is confused and incontinent of urine on admission. In developing a plan of care for the patient, an appropriate nursing intervention for the patient’s incontinence is to a. insert an indwelling catheter. b. apply absorbent incontinent pads. c. assist the patient to the bathroom q2hr. d. restrict fluids after the evening meal. In older or confused patients, incontinence may be avoided by using scheduled toileting times. Indwelling catheters increase the risk for UTI. Incontinent pads increase the risk for skin breakdown. Restricting fluids is not appropriate in a patient with dehydration. Cognitive Level: Application Text Reference: pp. Nursing Process: Planning NCLEX: Physiological Integrity 25. After her bath, a 62-year-old patient asks the nurse for a perineal pad, saying that she uses them because sometimes she leaks urine when she laughs or coughs. Which intervention is most appropriate to include in the care plan for the patient? a. Teach the patient how to perform Kegel exercises. b. Demonstrate how to perform Credé’s maneuver. c. Place commode at the patient’s bedside. d. Assist the patient to the bathroom q3hr. Exercises to strengthen the pelvic floor muscles will help reduce stress incontinence. The Credé maneuver is used to help empty the bladder for patients with overflow incontinence. Placing the commode close to the bedside and assisting the patient to the bathroom are helpful for functional incontinence. Cognitive Level: Application Text Reference: pp. Nursing Process: Planning NCLEX: Health Promotion and Maintenance 26. 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 for residual urine after voiding. b. Have the patient take small amounts of fluid frequently throughout the day. c. Reassure the patient that this is normal after rectal surgery due to anesthesia. d. Monitor the patient’s intake and output over the next few hours. An ultrasound scanner can be used to check for residual urine after the patient voids. Because the patient’s history and clinical manifestations are consistent with overflow incontinence, it is not appropriate to have the patient drink small amounts. Although overflow incontinence is not unusual after surgery, the nurse should intervene to correct the physiologic problem, not just reassure the patient. The patient may develop reflux into the renal pelvis as well as discomfort from a full bladder if the nurse waits to address the problem for several hours. Cognitive Level: Application Text Reference: p. 1182 Nursing Process: Implementation NCLEX: Physiological Integrity 27. A patient in the hospital has a history of urinary incontinence. Which nursing action will be included in the plan of care? a. Place a bedside commode near the patient’s bed. b. Use an ultrasound scanner to check urine residual after the patient voids. c. Demonstrate the use of the Credé maneuver to the patient. d. Teach the use of Kegel exercises to strengthen the pelvic floor. Environmental changes can make it easier for the patient to avoid incontinence for patients with urinary incontinence. Checking for residual urine and performing the Credé maneuver are interventions for overflow incontinence. Kegel exercises are useful for stress incontinence. Cognitive Level: Application Text Reference: p. 1181 Nursing Process: Planning NCLEX: Physiological Integrity 28. 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 need to buy seven new catheters weekly and use a new one every day.” b. “I will use a sterile catheter and gloves for each time I self-catheterize.” c. “I will need to take prophylactic antibiotics to prevent any urinary tract infections.” d. “I will wash the catheter with soap and water before and after each catheterization.” 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. Cognitive Level: Application Text Reference: p. 1188 Nursing Process: Evaluation NCLEX: Safe and Effective Care Environment 29. The nurse observes a nursing assistant (NA) doing all of the following when caring for a patient with a retention catheter. Which action requires that the nurse intervene? a. The NA uses an alcohol-based hand cleaner before performing catheter care. b. The NA disconnects the catheter from the drainage tube to obtain a specimen. c. The NA uses soap and water when cleaning around the urinary meatus. d. The NA tapes the catheter to the skin on the patient’s upper inner thigh. The catheter should not be disconnected from the drainage tube because this increases the risk for UTI. The other actions are appropriate and do not require any intervention. Cognitive Level: Application Text Reference: p. 1186 Nursing Process: Assessment NCLEX: Physiological Integrity 30. A patient undergoes a nephrectomy for massive trauma to the kidney resulting from a fall from a scaffold. Which assessment data obtained postoperatively are most important to communicate to the surgeon? a. Blood pressure is 102/48. b. Urine output is 20 ml/hr for 2 hours. c. Crackles are heard at both lung bases. d. Incisional pain level is 8/10. 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. Cognitive Level: Application Text Reference: p. 1188 Nursing Process: Assessment NCLEX: Physiological Integrity 31. A patient undergoing a left ureterolithotomy returns to the surgical unit with a left ureteral catheter and a urethral catheter in place. When caring for the patient, the nurse will plan to a. aspirate the ureteral catheter if output decreases. b. clamp the ureteral catheter unless output from the urethral catheter stops. c. keep the patient on bed rest until the ureteral catheter is discontinued. d. teach the patient about home care for both catheters. To avoid displacing the ureteral catheter, the patient is usually on bed rest until the catheter is removed. Aspi