Chapter 8
The charge nurse is reviewing the admission orders for Henrietta, who has been admitted with heart failure and renal insufficiency. It is a priority for the charge nurse to follow up with the provider about which order?
A. Digoxin 0.125 mg by mouth daily
B. Carvedilol (Coreg) 12.5 mg by mouth twice daily
C. Bumetanide (Bumex) 1 mg by mouth twice daily
D. Spironolactone (Aldactone) 25 mg by mouth three times a day
Answer: D
Rationale: Aldactone (spironolactone) is a potassium sparing diuretic, and in the patient with renal insufficiency, places them at risk for developing hyperkalemia.
How should assessment findings of blanched cool skin and leaking fluid at a peripheral infusion site be documented?
A. Infiltration
B. Infection
C. Extravasation
D. Phlebitis
Answer: A
Rationale: Fluid that has leaked into surrounding tissue will result in cool blanched skin. These are not signs of infection or inflammation. Blisters are seen with extravasation.
The nurse caring for a patient on a urology unit recognizes that which of the following laboratory values indicates the highest priority need for further assessment and intervention?
A. Serum uric acid 12.5 mg/dl
B. Serum calcium 8.8 mg/dl
C. Serum potassium 4.8 mEq/l
D. Serum BUN 20 mg/dl
Answer: A
Rationale: Normal uric acid values for adults are in the range of 3.5 to 8.0 mg/dL. Values greater than 12.0 mg/dL are critical and warrant immediate intervention. Excess uric acid is termed hyperuricemia. It can result in the development of gout; inflammatory arthritis is caused by uric acid crystals in the joints, and, and, in severe cases, can cause renal damage. The other values are within normal limits.
The nurses recognizes that the older adult patient may have a reduced ability to concentrate urine, which is attributed to which of the following?
A. A reduction in bladder receptors
B. Thickening of the basement membrane of the Bowman’s capsule
C. A decrease in the number of functioning nephrons
D. A thickening of the efferent arteriole
Answer: C
Rationale: Older adults have a reduced number of functioning nephrons, which impairs the ability to concentrate urine.
The lower urinary tract includes:
A. Kidneys and ureters
B. Bladder and ureters
C. Bladder and urethra
D. Kidneys and bladder
Answer: C
Rationale: Kidney and ureters are a part of the upper urinary tract.
Which statement by Henrietta about potassium supplements indicates the need for further teaching?
A. “In addition to the potassium supplement, I will eat a banana every day.”
B. “I can liberally use salt substitute with my meals.”
C. “I should stop taking the K-Tab if I have no leg cramps.”
D. “Fruits and vegetables are a good source of potassium.”
Answer: B
Rationale: Salt substitutes primarily contain potassium and excessive use could result in hyperkalemia.
The nurse understands which is the result of administering hypertonic solutions?
A. Cells become hydrated.
B. Free water enters the vascular space.
C. Fluid shifts from the intracellular space into the intravascular space.
D. There is no shift into the intracellular compartment
Answer: C
Rationale: When hypertonic solutions are administered intravenously, fluid moves from inside the cells into the vascular space due to the higher osmolarity in the intravascular space.
The nurse recognizes which of the following patients is at the highest risk of developing bladder cancer?
A. A 75-year-old male with a history of diabetes
B. A 40-year-old female with a 20-year smoking history
C. A 30-year-old female who works as a hairdresser
D. A 52-year-old female with a history of frequent UTIs
Answer: B
Rationale: Smoking is the greatest risk factor for the development of bladder cancer. Diabetes and frequent UTIs are not known to increase the risk of developing bladder cancer. Certain occupations, including hairdressing, increase the risk of developing bladder cancer, yet smoking remains the greatest risk factor.
The nurse should intervene immediately if the patient post renal transplantation is noted to have which of the following symptoms?
A. Weight loss, hypotension, reduced urine output
B. Fever, reduced urine output, elevated blood pressure
C. Weight gain, hypotension, increased urine output
D. Increased urine output, hypertension, fever
Answer: B
Rationale: The priority is the combination of fever, reduced urine output, and elevated BP which may be indicative of the presence of AKI related to transplant rejection. Hypotension, changes in weight, and reduced urine output should be evaluated. Increased urine output is expected due to improved BUN clearance and OR fluids.
The patient is prescribed CIC for incontinence management. The nurse tells the patient that this will do what? (Select all that apply.)
A. Decrease urinary tract infection precipitated by retention of urine
B. Reestablish control of urinary elimination
C. Prevent frequent feeling of the need to void
D. Decrease episodes of hematuria
E. Cure incontinence
Answer: A, B, and C
Rationale: CIC will not decrease episodes of hematuria or cure incontinence.
The nurse is providing discharge instructions to Henrietta regarding dietary sources of potassium. The nurse does not recommend which food as a source of high potassium content?
A. Baked potato
B. Apple
C. Banana
D. Cooked spinach
Answer: B
Rationale: An apple has a mid-level of potassium content while the other items have high potassium content.
If a hemolytic transfusion reaction is suspected, what is the nurse’s priority action?
A. Slow the transfusion and notify the provider.
B. Stop the transfusion but maintain the infusion with 0.9% sodium chloride.
C. Stop the transfusion and change the infusion site.
D. Send a blood specimen for repeated blood typing.
Answer: B
Rationale: The infusion needs to be stopped to avoid administration of any further blood product, but the IV needs to be maintained in case immediate venous access is required for emergency medications.
Which of the following assessment and laboratory findings is most indicative of the presence of infection?
A. 1,500 colonies of bacteria/ml on a urinalysis
B. Negative CVA tenderness on percussion
C. Tenderness to palpation of the abdomen
D. Isolation of streptococcus in urine culture
Answer: D
Rationale: Although 1,500 colonies of bacteria/ml may indicate a UTI, it is not diagnostic of UTI. Therefore, a urine culture is required to isolate any bacteria present. In cases of kidney infection, CVA percussion would produce a positive sign of tenderness and pain. Abdominal tenderness with palpation can be attributed to many causes and is not the most indicative of infection in this case.
The nurse includes which dietary information in the teaching plan about the management of chronic kidney disease?
A. Decrease fluid intake and protein intake, decrease carbohydrate intake
B. Increase fluid intake, decrease carbohydrate intake and protein intake
C. Decrease fluid intake and protein intake, increase carbohydrate intake
D. Increase fluid intake, increase carbohydrate intake and protein intake
Answer C
Rationale: It is important to decrease fluid intake because people with CKD may have a reduction in urine output, causing fluid to build up in the body; this puts the patient at further risk for volume overload. Decreasing protein intake will limit the buildup of waste products in the body, and increasing carbohydrates will provide patients with a good source of energy that is lost with the low-protein diet.
This structure provides voluntary control of micturition:
A. External sphincter
B. Detrusor muscle
C. Posterior urethral valves
D. Internal sphincter
Answer: A
Rationale: The external sphincter is under voluntary control. The internal sphincter is involuntary. The detrusor muscle is found in the wall of the bladder. Posterior urethral values are found in the urethra to act as a valve to block urine flow.
When providing discharge instructions for Henrietta, the nurse should include which of the following? (Select all that apply.)
A. Weigh herself daily at the same time
B. Limit fluid intake to 3 L per day
C. Limit salt intake
D. Increase use of fresh fruits and vegetables in her diet
E. Report a 3-lb weight gain in 2 days to her primary care provider
Answer: A, C, D, and E
Rationale: It is important for her to weigh herself daily as fluid retention increases body weight. Her fluids should be limited to less than 1.2 liters/day. Salt intake is limited due to risk of fluid retention which can exacerbate her underlying heart failure. Green leafy vegetables are not high sources of potassium.
An 80-year-old male presents for a physical examination and reports changes in his urinary pattern including urinary frequency, hesitancy, and a slow stream of urine. As the nurse, you recognize these findings are likely attributed to which of the following?
A. Decreased bladder capacity related to age
B. Renal failure
C. Enlargement of the prostate gland
D. Decrease in size of the kidneys
Answer: C
Rationale: A majority of males experience enlargement of the prostate gland, usually benign, with increasing age. This results in compression of the urethra and can explain subjective findings such as urinary frequency, hesitancy, straining upon urination, and a slow stream of urine. Although the bladder capacity and size of the kidneys decrease with age, these do not explain this patient’s subjective reports. In cases of renal failure, the amount and frequency of urine typically decreases.
The nurse is screening patient for their risk of developing renal cell cancer. The nurse should consider which patient at greatest risk?
A. 76-year-old African American female
B. 50-year-old Caucasian male
C. 24-year-old Caucasian male
D. 50-year-old African American male
Answer: D
Rationale: African Americans and American Indians and Alaskan natives have slightly higher rates of RCC than Caucasians; the exact reasons are unclear. RCC is twice as common in men than women. This is attributed to men more likely to be smokers and who have increased exposure chemicals and occupational hazards.
Motor stimulation of the bladder that mediates bladder contraction is provided by:
A. Sympathetic nervous system
B. Efferent innervation
C. Parasympathetic nervous system
D. Detrusor muscle
Answer: C
Rationale: Bladder control is mediated by the interplay between the sympathetic and parasympathetic nervous systems. The parasympathetic system provides the stimulus for bladder contraction. The sympathetic nervous system mediates bladder storage. The detrusor muscle is found in the wall of the bladder. It relaxes or contracts based on nervous stimulation. Efferent innervation is the process of carrying an impulse toward the intended muscle.
Which statement by Henrietta indicates the need for further teaching about hyperkalemia?
A. “It is normal to have heart palpitations.”
B. “Fatigue and weakness are signs of low potassium.”
C. “Some of my medications make me at risk for high potassium.”
D. “I may have numbness and tingling when my potassium is high.”
Answer: A
Rationale: Patients with hyperkalemia may complain of generalized fatigue, palpitations, paresthesia, or weakness. The most important and potentially life threatening consequence of hyperkalemia is effects on the cardiac electrical conduction system.
A 58-year-old female with a history of diabetes presents for a routine physical examination. A urinalysis is obtained and evaluated. The results indicate the presence of glucose in the urine. The nurse recognizes that this indicates which of the following?
A. Serum glucose of 150 mg/dl
B. Serum glucose of 250 mg/dl
C. Serum BUN of 12 mg/dl
D. Serum BUN of 35 mg/dl
Answer: B
Rationale: The presence of glucose in the urine occurs when the renal threshold for glucose (220 mg/dL) is exceeded. Serum BUN does not affect the presence of glucose in the urine.