Lewis Med-Surg, Chapter 50: Renal and Urological Problems

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

a. Suprapubic pain

b. Bladder distention

c. Foul-smelling urine

d. Costovertebral tenderness

ANS: D

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

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

a. kidney stones.

b. bladder cancer.

c. bladder infection.

d. interstitial cystitis.

ANS: B

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

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

a. Assist the patient to the bathroom q3hr.

b. Place a commode at the patient's bedside.

c. Demonstrate how to perform the Credé maneuver.

d. Teach the patient how to perform Kegel exercises.

ANS: D

Exercises to strengthen the pelvic floor muscles will help reduce stress incontinence. The 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.

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

a. Application of ostomy appliances

b. Catheterization technique and schedule

c. Analgesic use before emptying the pouch

d. Use of barrier products for skin protection

ANS: B

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

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

a. anxiety related to effects of procedure on lifestyle.

b. disturbed body image related to change in body function.

c. readiness for enhanced coping related to need for information.

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

ANS: B

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

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

a. The patient is using opioids for pain.

b. The patient has noticed clots in the urine.

c. The patient is very anxious about the cancer.

d. The patient is voiding every 4 hours at night.

ANS: B

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

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

a. premedicating to prevent nausea.

b. where to obtain wigs and scarves.

c. the importance of oral care during treatment.

d. the need to empty the bladder before treatment.

ANS: D

The patient will be asked to empty the bladder before instillation of the chemotherapy.

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

a. Insert a urinary retention catheter.

b. Schedule an intravenous pyelogram.

c. Administer lorazepam (Ativan) 0.5 mg PO.

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

ANS: A

The 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.

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

a. Assess for symptoms of urinary tract infection (UTI).

b. Change the ostomy appliance.

c. Choose the appropriate ostomy bag.

d. Monitor the appearance of the stoma.

ANS: B

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

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

a. Insert a straight catheter and drain the bladder.

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

c. Encourage the patient to drink several glasses of water.

d. Teach the patient how to do isometric perineal exercises.

ANS: B

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

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

a. Taping the catheter to the skin on the patient's upper inner thigh

b. Cleaning around the patient's urinary meatus with soap and water

c. Using an alcohol-based hand cleaner before performing catheter care

d. Disconnecting the catheter from the drainage tube to obtain a specimen

ANS: D

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

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

a. Blood pressure is 102/58.

b. Incisional pain level is 8/10.

c. Urine output is 20 mL/hr for 2 hours.

d. Crackles are heard at both lung bases.

ANS: C

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

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

a. Cloudy appearing urine

b. Hypotonic bowel sounds

c. Heart rate 102 beats/minute

d. Continuous drainage from stoma

ANS: C

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