Chills could indicate the onset of acute infection that can progress to septic shock. Dizziness would not be an anticipated symptom after a cystoscopy. Pink-tinged urine and bladder spasms are common after cystoscopy.
2.Answer b.
After pelvic surgery, there is an increased chance of thrombophlebitis owing to the pelvic manipulation that can interfere with circulation and promote venous stasis.Peritonitis is a potential complication of any abdominal surgery, not just pelvic surgery. Ascites is most frequently an indication of liver disease. Inguinal hernia may be caused by an increase in intra-abdominal pressure or a congenital weakness of the abdominal wall; ventral hernia occurs at the site of a previous abdominal incision.
3.Answer d .
Mucus is secreted by the intestinal segment used to create the conduit and is a normal occurrence. The client should be encouraged to maintain a large fluid intake to help fl ush the mucus out of the conduit. Because mucus in the urine is expected, it is not necessary to change the appliance bag or to notify the physician. The mucus is not an indication of an infection, so a urine culture is not necessary.
4.Answer a.
The most important reason for attaching the appliance to a standard urine collection bag at night is to prevent urine refl ux into the stoma and ureters, which can result in infection. Use of a standard
collection bag also keeps the appliance from separating from the skin and helps prevent urine leakage from an overly full bag, but the primary purpose is to prevent reflux of urine. A client with a
urinary diversion should drink 2,000 to 3,000 mL of fluid each day; it would be inappropriate to suggest decreasing fluid intake.
5.Answer b.
A reusable appliance should be routinely cleaned with soap and water.
6.Answer c.
The priority nursing goal for this client is to alleviate the pain, which can be excruciating.
Prevention of urinary tract complications and alleviation of nausea are appropriate throughout the client’s hospitalization, but relief of the severe pain is a priority. The client is at little risk for fluid and
electrolyte imbalance.
7.Answer b.
After an IVP, the nurse should encourage fl uids to decrease the risk of renal complications caused by the contrast agent. There is no need to place the client on bed rest or administer a laxative.An IVP would not cause hematuria.
8.Answer b.
The pain associated with renal colic due to calculi is commonly referred to the groin and bladder in female clients and to the testicles in male clients. Nausea, vomiting, abdominal cramping,and diarrhea may also be present. Nephritis or urine retention is an unlikely cause of the referredpain.The type of pain described in this situation is unlikely to be caused by additional stone formation
9.Answer a, b, c, d.
Elevation of the head of the bed will promote ease of breathing. Respiratory manifestations of acute renal failure include shortness of breath, orthopnea, crackles, and the potential for pulmonary edema. Therefore, priority is placed on facilitation of respiration.
The nurse should assess the vital signs because the pulse and respirations will be elevated. Establishing a site for I.V. therapy will become important because fl uids will be administered I.V. in addition to orally. The physician will need to be contacted for further orders; there is no need to contact the hemodialysis unit.
10.Answer d.
Oliguria is the most common initial symptom of acute renal failure. Anuria is rarely the initial symptom. Dysuria and hematuria are not associated with acute renal failure.
11.Answer d.
Polystyrene sulfonate, a cation-exchange resin, causes the body to excrete potassium through the gastrointestinal tract. In the intestines, particularly the colon, the sodium of the resin is partially
replaced by potassium. The potassium is then eliminated when the resin is eliminated with feces.Although the result is to increase potassium excretion,the specifi c method of action is the exchange
of sodium ions for potassium ions. Polystyrene sulfonate does not release hydrogen ions or increase calcium absorption.
12.Answer d.
Signs and symptoms of an external access shunt infection include redness, tenderness, swelling,and drainage from around the shunt site. The absence of a bruit indicates closing of the shunt.
Sluggish capillary refi ll time and coolness of the extremity indicate decreased blood flow to the extremity.
13.Answer b.
The classic symptoms of cystitis are severe burning on urination, urgency, and frequent urination.Systemic symptoms, such as fever and nausea and vomiting, are more likely to accompany pyelonephritis
than cystitis. Hematuria may occur, but it is not as common as frequency and burning.
14.Answer d.
Instructions should be as specifi c as possible,and the nurse should avoid general statements such as “a lot.” A specifi c goal is most useful. A mix of fl uids will increase the likelihood of client
compliance. It may not be suffi cient to tell the client to drink twice as much as or 1 quart more than she usually drinks if her intake was inadequate to begin with.
15.Answer c.
A disadvantage of peritoneal dialysis in long-term management of chronic renal failure is that it requires large blocks of time. The risk of hemorrhage or hepatitis is not high with peritoneal dialysis. Peritoneal dialysis is effective in maintaining a client’s fl uid and electrolyte balance.
16.Answer b.
Because the client has a permanent catheter in place, blood-tinged drainage should not occur.Persistent blood-tinged drainage could indicate damage to the abdominal vessels, and the physician
should be notifi ed. The bleeding is originating in the peritoneal cavity, not the kidneys. Too-rapid infusion of the dialysate can cause pain, not bloodtinged drainage.
17.Answer b.
Because hypotension is a complication associated with peritoneal dialysis, the nurse records intake and output, monitors vital signs,and observes the client’s behavior. The nurse also encourages visiting and other diversional activities.A client on peritoneal dialysis does not need to be placed in a bed with padded side rails or kept on NPO status.
18.Answer b.
Weight loss is expected because of the removal of fl uid. The client’s weight before and after dialysis is one measure of the effectiveness of treatment. Blood pressure usually decreases because
of the removal of fl uid. Hematuria would not occur after completion of peritoneal dialysis. Dialysis only minimally affects the damaged kidneys’ ability to manufacture urine.
19.Answer c.
Dietary management for clients with chronic renal failure is usually designed to restrict protein, sodium, and potassium intake. Protein intake is reduced because the kidney can no longer excrete the byproducts of protein metabolism. The degree of dietary restriction depends on the degree of renal impairment. The client should also receive a high-carbohydrate diet along with appropriate vitamin and mineral supplements. Calcium requirements remain 1,000 to 2,000 mg/day.
20.Answer c.
A client in renal failure develops hyperphosphatemia that causes a corresponding excretion of the body’s calcium stores, leading to renal osteodystrophy. To decrease this loss, aluminum hydroxide gel is prescribed to bind phosphates in the intestine and facilitate their excretion. Gastric hyperacidity is not necessarily a problem associated with chronic renal failure. Antacids will not prevent
Curling’s stress ulcers and do not affect metabolic acidosis.
21.Answer d.
Instructions should be as specifi c as possible,and the nurse should avoid general statements such as “a lot.” A specifi c goal is most useful. A mix of fl uids will increase the likelihood of client
compliance. It may not be suffi cient to tell the client to drink twice as much as or 1 quart more than she usually drinks if her intake was inadequate to begin with.
Proudly powered by