Lewis Medical Surgical Nursing Chap 50: Renal and Urologic Problems

A 46-yr-old female patient returns to the clinic with continued dysuria after being treated with trimethoprim and sulfamethoxazole for 3 days. Which action will the nurse plan to take?

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

b. Obtain a midstream urine specimen for culture and sensitivity testing.

c. Suggest that the patient use acetaminophen (Tylenol) to relieve symptoms. d. Tell the patient to take the trimethoprim and sulfamethoxazole for 3 more days

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

Which statement by a 22-yr-old female patient with cystitis indicates to the nurse that instruction about preventing future urinary tract infections (UTIs) has been effective?

a. ―I can use vaginal antiseptic sprays to reduce bacteria.‖

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

c. ―I will wash with soap and water before sexual intercourse.‖

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

ANS: D Voiding every 3 to 4 hours is recommended to prevent UTIs. Use of vaginal sprays is discouraged. The bladder should be emptied before and after intercourse, but cleaning with soap and water prior to intercourse is not necessary to prevent UTI. A quart of fluids is insufficient to provide adequate urine output to decrease risk for UTI.

Which information about phenazopyridine will the nurse teach the patient with a urinary tract infection (UTI)?

a. Take the drug for at least 7 days.

b. The drug may cause photosensitivity.

c. The drug may change your urine color.

d. Take the drug before sexual intercourse.

ANS: C Patients should be taught that phenazopyridine will color the urine deep orange. Urinary analgesics would be taken as needed for dysuria and should be needed for only a few days until the prescribed antibiotics decrease the bacterial count. Phenazopyridine does not cause photosensitivity

Which finding by the nurse will be most helpful in determining whether a 67-yr-old patient with benign prostatic hyperplasia has an upper urinary tract infection (UTI)?

a. Bladder distention

b. Foul-smelling urine

c. Suprapubic discomfort

d. Costovertebral tenderness

ANS: D Costovertebral tenderness is characteristic of pyelonephritis. Bladder distention, foul-smelling urine, and suprapubic discomfort are characteristic of a lower UTI and are likely to be present if the patient also has an upper UTI.

Which statement by a patient with interstitial cystitis indicates to the nurse that further instruction is needed?

a. ―I should stop having coffee and orange juice for breakfast.‖

b. ―I will buy calcium glycerophosphate (Prelief) at the pharmacy.‖

c. ―I will start taking high potency multiple vitamins every morning.‖

d. ―I should call the doctor about increased bladder pain or foul urine.‖

ANS: C High-potency multiple vitamins may irritate the bladder and increase symptoms; the patient should take a multivitamin containing no more than the recommended daily allowance for essential vitamins. The other patient statements indicate good understanding of the teaching.

Which information in the patient history would indicate a possible cause of acute glomerulonephritis?

a. Recent bladder infection

b. History of kidney stones

c. Recent sore throat and fever

d. History of high blood pressure

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

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

a. The urine dipstick is negative for nitrites.

b. The patient denies pain or burning with voiding.

c. The antistreptolysin-O (ASO) titer has decreased.

d. The periorbital and peripheral edema have resolved.

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

A patient who has nephrotic syndrome develops flank pain. Which treatment will the nurse plan to explain to this patient?

a. Antifungals

b. Antibacterials

c. Anticoagulants

d. Antihypertensives

ANS: C Flank pain in a patient with nephrotic syndrome suggests a renal vein thrombosis and anticoagulation is needed. Antibiotics are used to treat a patient with flank pain caused by pyelonephritis. Fungal pyelonephritis is uncommon and is treated with antifungals. Antihypertensives are used if the patient has high blood pressure.

An adult patient is admitted to the hospital with new-onset nephrotic syndrome. Which assessment data will the nurse expect?

a. Poor skin turgor

b. Recent weight gain

c. Elevated urine ketones

d. Decreased blood pressure

ANS: B The patient with a nephrotic syndrome will have weight gain associated with edema. Hypertension is a clinical manifestation of nephrotic syndrome. Skin turgor is normal because of the edema. Urine protein is high. Ketones are not related to nephrotic syndrome

A patient has had recurrent uric acid kidney stones. Which diet items would the nurse recommend that the patient avoid or limit?

a. Milk and cheese

b. Sardines and liver

c. Spinach and chocolate

d. Legumes and dried fruit

ANS: B 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

Which topic would the nurse include when teaching the patient ways to prevent the recurrence of kidney stones?

a. Using a filter to strain all urine

b. Drinking 3000 mL of fluid each day

c. Avoiding dietary sources of calcium

d. Choosing diuretic fluids such as coffee

ANS: B A fluid intake of 2000 to 3000 mL/day is recommended to help flush out minerals before stones can form. Avoidance of calcium is not usually recommended for patients with kidney stones. Coffee tends to increase stone recurrence. Straining all urine routinely after a stone has passed will not prevent stones.

Which topic would the nurse include when planning a teaching session for a patient with benign nephrosclerosis?

a. Preventing bleeding with anticoagulants

b. Obtaining and documenting daily weight

c. Monitoring and recording blood pressure

d. Measuring daily intake and output volumes

ANS: C Hypertension is the major manifestation 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.

A 28-yr-old male patient has just been diagnosed with polycystic kidney disease. Which information would the nurse include during the first teaching session?

a. Complications of renal transplantation

b. Methods for treating severe chronic pain

c. Options to consider for genetic counseling

d. Differences between hemodialysis and peritoneal dialysis

ANS: C Because a 28-yr-old patient may be considering having children, the nurse would include information about genetic counseling when teaching the patient. A patient with good healthmanagement 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

A young adult male patient seen at the primary care clinic reports feeling continued fullness after voiding and a split, spraying urine stream. Which item in the patient's history is consistent with the patient's reported concerns?

a. Gonococcal urethritis

b. Recent kidney trauma

c. Recurrent bladder infection

d. Benign prostatic hyperplasia

ANS: A The patient's clinical manifestations are consistent with urethral strictures, a possible complication of gonococcal urethritis. The symptoms are not consistent with benign prostatic hyperplasia, kidney trauma, or bladder infection

An adult smokes two packs of cigarettes daily. For which condition is the individual at increased risk?

a. Kidney stones

b. Bladder cancer

c. Bladder infection

d. Interstitial cystitis

ANS: B About half of bladder cancers are related to cigarette smoking. The patient's risk for developing interstitial cystitis, urinary tract infection, or kidney stones will not be reduced by quitting smoking

A 68-yr-old patient admitted to the hospital with dehydration is confused and incontinent of urine. Which action would the nurse include in the plan of care? a. Restrict fluids between meals and after the evening meal.

b. Insert an indwelling catheter until the symptoms have resolved.

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

d. Apply absorbent adult incontinence diapers and pads over the bed linens

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

A 55-yr-old woman admitted for shoulder surgery asks the nurse for a perineal pad, stating that laughing or coughing causes leakage of urine. Which intervention is appropriate to include in the care plan?

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

b. Assist the patient to the bathroom every 3 hours.

c. Demonstrate how to perform the Credé maneuver.

d. Teach the patient how to perform Kegel exercises.

ANS: D Kegel 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.

Following rectal surgery, a patient voids about 50 mL of urine every 30 to 60 minutes for the first 4 hours. Which nursing action is the priority?

a. Encourage the patient to drink more fluids.

b. Plan to monitor the patient's intake and output.

c. Use an ultrasound scanner to check the postvoiding residual volume.

d. Reassure the patient that urinary problems are common after rectal surgery.

ANS: C The patient's history and clinical manifestations are consistent with overflow incontinence, so an ultrasound scanner can be used to check for residual urine after the patient voids. The other interventions may also be useful, but the priority patient problem is the potentially overfilled bladder.

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

a. Demonstrate the use of the Credé maneuver.

b. Teach exercises to strengthen the pelvic floor.

c. Place a bedside commode close to the patient's bed.

d. Use an ultrasound scanner to check postvoiding residuals.

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

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

a. ―I will use a sterile catheter and gloves for each catheterization.‖

b. ―I will buy seven new catheters weekly and use a new one every day.‖

c. ―I will take prophylactic antibiotics to prevent urinary tract infections.‖

d. ―I will wash the catheter carefully before and after each catheterization.‖

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

After ureterolithotomy, a patient has a urethral catheter and a left ureteral catheter in place. Which action will the nurse include in the plan of care?

a. Apply continuous steady tension to the ureteral catheter.

b. Provide teaching about how to remove and replace the catheters at home. c. Call the health care provider if the ureteral catheter output drops suddenly. d. Clamp the ureteral catheter off when output from the urethral catheter stops

ANS: C The health care provider should be notified urgently if the ureteral catheter output decreases because obstruction of this catheter may result in an increase in pressure in the renal pelvis. Tension on the ureteral catheter should be avoided to prevent catheter displacement. To avoid pressure in the renal pelvis, the catheter is not clamped. The catheters are indwelling, and the patient will not be responsible for removing or replacing them.

An older adult with bladder cancer had a cystectomy with creation of an Indiana pouch. Which topic will the nurse include in patient teaching?

a. Application of ostomy appliances

b. Barrier products for skin protection

c. Catheterization technique and schedule

d. Analgesic use before emptying the pouch

ANS: C The Indiana pouch is a continent diversion; the patient can 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.

After change-of-shift report, which patient would the nurse assess first?

a. Patient who has cloudy urine after bladder reconstruction

b. Patient with a urethral stricture who has not voided for 12 hours

c. Patient who voided bright red urine after returning from lithotripsy

d. Patient with polycystic kidney disease whose blood pressure is 186/98 mm Hg

ANS: B Not voiding for 12 hours suggests acute urinary retention, which is a medical emergency. The nurse will need to assess the patient and consider whether to insert a retention catheter. The other patients will be assessed, but their findings are consistent with their diagnoses and do not require immediate assessment or intervention

Which information from a patient who had a transurethral resection with fulguration for bladder cancer 3 days ago is most important to report to the health care provider?

a. The patient voids every 4 hours.

b. The patient takes opioids for pain.

c. The patient reports clots in the urine.

d. The patient is anxious about the cancer.

ANS: C 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.

Which topic would the nurse teach when preparing a patient with bladder cancer for intravesical chemotherapy?

a. Coping with hair loss

b. Urinating before the instillation

c. Premedicating to prevent nausea

d. Maintaining oral care during the treatments

ANS: B The patient will be asked to urinate and empty the bladder before instillation of the chemotherapy. Systemic side effects are not expected with intravesical chemotherapy.

Nursing staff on a hospital unit are reviewing rates of health care-associated infections (HAI) of the urinary tract. Which nursing action will be most helpful in decreasing the risk for urinary HAI in patients admitted to the hospital?

a. Testing urine with a dipstick daily for nitrites

b. Avoiding unnecessary bladder catheterization

c. Encouraging adequate oral fluid and nutritional intake

d. Providing perineal hygiene to patients daily and as needed

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

Which assessment data reported by a patient is consistent with a lower urinary tract infection (UTI)?

a. Low urine output

b. Bilateral flank pain

c. Nausea and vomiting

d. Burning on urination

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

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

a. Flank tenderness to palpation

b. Blood pressure 90/48 mm Hg

c. Cloudy and foul-smelling urine

d. Temperature 100.1F (57.8C)

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

A patient who is diagnosed with nephrotic syndrome has ascites and 4+ leg edema. Which patient problem is present, based on these findings?

a. Fatigue

b. Fluid imbalance

c. Inadequate tissue perfusion

d. Nutritionally compromised

ANS: B Edema and ascites are evidence of a fluid imbalance or excess fluid volume. There are no data provided to support the other problems.

A 76-yr-old with benign prostatic hyperplasia (BPH) is agitated and confused, with a markedly distended bladder. Which intervention prescribed by the health care provider would the nurse implement first?

a. Insert an indwelling urinary catheter.

b. Draw blood for a serum creatinine level.

c. Schedule an intravenous pyelogram (IVP).

d. Administer lorazepam (Ativan) 0.5 mg PO.

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 after the bladder distention is corrected, and sedative drugs would be used cautiously in older patients. The IVP may be done as a diagnostic test but does not need to be done urgently

Which nursing action is of highest priority for a patient with kidney stones who is being admitted to the hospital with gross hematuria and severe colicky left flank pain?

a. Administer prescribed analgesics.

b. Monitor temperature every 4 hours.

c. Encourage increased oral fluid intake.

d. Give antiemetics as needed for nausea.

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

The nurse is caring for a patient who has had an ileal conduit for several years. Which nursing action could be delegated to assistive personnel (AP)?

a. Change the ostomy appliance.

b. Choose the appropriate ostomy bag.

c. Monitor the appearance of the stoma.

d. Assess for possible urinary tract infection.

ANS: A Changing the ostomy appliance for a stable patient could be done by AP. 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 registered nurse (RN).

hich assessment finding is most important to report to the health care provider regarding a patient who has had left-sided extracorporeal shock wave lithotripsy?

a. Blood in urine

b. Left flank bruising

c. Left flank discomfort

d. Decreased urine output

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

A patient is unable to void after having an open loop resection and fulguration of the bladder. Which action would the nurse implement?

a. Assist the patient to soak in a 15-minute sitz bath.

b. Restrict oral fluids to equal previous urine volume.

c. Insert a straight urethral catheter and drain the bladder.

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

ANS: A Sitz baths will relax the perineal muscles and promote voiding. The patient should be encouraged to drink fluids. Kegel exercises are helpful in the prevention of incontinence but would not be helpful for a patient experiencing retention. Catheter insertion increases the risk for urinary tract infection and should be avoided when possible.

The nurse observes unlicensed assistive personnel (AP) taking the following actions when caring for a female patient with a urethral catheter. Which action requires that the nurse intervene?

a. Securing the catheter to the patient's upper inner thigh

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

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

d. Using an alcohol-based gel hand cleanser before performing catheter care

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

A 48-yr-old male patient who weighs 242 lb (110 kg) undergoes a left nephrectomy for massive kidney trauma from a motor vehicle crash. Which postoperative assessment finding is most important to communicate to the surgeon?

a. Blood pressure is 102/58.

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

c. Incisional pain level reported as 9/10.

d. Crackles present at bilateral lung bases.

ANS: B 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 perfusion to the remaining kidney 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.

A patient had a cystectomy with an ileal conduit yesterday. Which new assessment data is most important for the nurse to communicate to the health care provider?

a. Cloudy appearing urine

b. Heart rate 102 beats/min

c. Hypoactive bowel sounds

d. Continuous stoma drainage

ANS: B 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. Hypoactive bowel sounds are expected after bowel surgery. Continuous drainage of urine from the stoma is normal.

A patient with a history of polycystic kidney disease is admitted to the surgical unit after having shoulder surgery. Which routine postoperative order is most important for the nurse to discuss with the health care provider?

a. Give ketorolac 10 mg PO PRN for pain.

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

c. Order regular diet after patient is awake and alert.

d. Draw blood urea nitrogen (BUN) and creatinine in 2 hours

ANS: A The nonsteroidal antiinflammatory drugs (NSAIDs) such as ketorolac should be avoided in patients with decreased renal function because nephrotoxicity is a potential adverse effect. The other orders do not need any clarification or change.

A patient seen in the clinic for a bladder infection describes the following symptoms. Which

information is most important for the nurse to report to the health care provider?

a. Urinary urgency

b. Left-sided flank pain

c. Intermittent hematuria

d. Burning with urination

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

A female patient in the urology clinic is diagnosed with monilial urethritis. Which action will the nurse include in the plan of care?

a. Teach the patient about the use of antifungal medications.

b. Tell the patient to avoid tub baths until the symptoms resolve.

c. Instruct the patient to refer recent sexual partners for treatment.

d. Tell the patient to avoid nonsteroidal antiinflammatory drugs (NSAIDs)

ANS: A Monilial urethritis is caused by a fungus and antifungal medications such as nystatin or fluconazole are usually used as treatment. Because monilial urethritis is not sexually transmitted, there is no need to refer sexual partners. Warm baths and NSAIDS may be used to treat symptoms.

Which action will the nurse anticipate taking for an otherwise healthy 50-yr-old who has just been diagnosed with stage 1 renal cell carcinoma?

a. Prepare patient for a renal biopsy.

b. Provide preoperative teaching about nephrectomy.

c. Teach the patient about chemotherapy medications.

d. Schedule for a follow-up appointment in 3 months.

ANS: B The treatment of choice in patients with localized renal tumors who have no co-morbid conditions is partial or total nephrectomy. A renal biopsy will not be needed in a patient who has already been diagnosed with renal cancer. Chemotherapy is used for metastatic renal cancer. Because renal cell cancer frequently metastasizes, treatment will be started as soon as possible after the diagnosis.

Which information about a patient with anti-glomerular basement membrane (GBM) disease/Goodpasture syndrome requires the most rapid action by the nurse?

a. Blood urea nitrogen level is 70 mg/dL.

b. Elevated level of anti-GBM antibodies.

c. Urine output over the last 2 hours is 30 mL.

d. Audible crackles bilaterally to scapular level.

ANS: D Crackles heard to a high level in the chest indicate a need for rapid actions such as assessment of O2 saturation, reporting the findings to the health care provider, initiating O2 therapy, and dialysis. The other findings will be reported but are typical of anti-glomerular basement membrane (GBM) disease/Goodpasture syndrome and do not require immediate nursing action.

A patient is admitted to the emergency department with possible renal trauma after an automobile accident. Which prescribed intervention will the nurse implement first?

a. Check blood pressure and heart rate.

b. Administer morphine sulfate 4 mg IV.

c. Transport to radiology for an intravenous pyelogram.

d. Insert a urethral catheter and obtain a urine specimen.

ANS: A Because the kidney is very vascular, the initial action with renal trauma will be assessment for bleeding and shock. The other actions may be important after the patient's cardiovascular status has been determined and stabilized

A patient has been diagnosed with urinary tract stones that are high in uric acid. Which foods will the nurse teach the patient to avoid or limit? (Select all that apply.)

a. Milk

b. Liver

c. Spinach

d. Chicken

e. Cabbage

f. Chocolate

ANS: B, D Meats contain purines, which are metabolized to uric acid. The other foods might be restricted in patients who have calcium or oxalate stones