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52: Renal System
PRACTICE QUESTIONS
1. A nurse has an order to obtain a sample for urinalysis from a client with an indwelling urinary catheter. The nurse would avoid which of the following, which could contaminate the specimen? 1. Obtaining the specimen from the urinary drainage bag 2. Clamping the tubing of the drainage bag 3. Aspirating a sample from the port on the tubing attached to the drainage bag 4. Wiping the port on the tubing with an alcohol swab before inserting the syringe Answer: 1 Rationale: A urine specimen is not taken from the urinary drainage bag. Urine undergoes chemical changes while sitting in the bag, and does not necessarily reflect current client status. In addition, it may become contaminated with bacteria from opening the system. Options 2, 3, and 4 are correct actions. Test-Taking Strategy: Note the key word, avoid. This word indicates a false response question and that you need to select the incorrect action. Recalling the basic principles of asepsis will direct you to option 1. Review this procedure if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Safe, Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Renal Reference: deWit, S. (2005). Fundamental concepts and skills for nursing. Philadelphia: W.B. Saunders, p. 533. 2. A nurse is caring for the client who has had a renal biopsy. Which intervention would the nurse avoid in the care of the client after this procedure? 1. Encouraging fluids to at least 3 L in the first 24 hours 2. Administering pain medication as prescribed 3. Testing serial urine samples with dipsticks for occult blood 4. Ambulating the client in the room and hall for short distances Answer: 4 Rationale: After renal biopsy, the nurse ensures that the client remain in bed for at least 24 hours. Vital signs and puncture site assessments are done frequently during this time. Encouraging fluids is done to reduce possible clot formation at the biopsy site. A Hematest is done on serial urine samples with urine dipsticks to evaluate bleeding. Analgesics are often needed to manage the renal colic pain that some clients feel after this procedure. Test-Taking Strategy: Begin to answer this question by recalling that pain and bleeding are potential concerns after this procedure. This will help eliminate options 2 and 3. From the remaining options, you need to recall that encouraging fluids will reduce clotting at the site, whereas ambulation could initiate or enhance bleeding at the biopsy site. Review care of the client following a renal biopsy if you had difficulty with this question. Level of Cognitive Ability: Application

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Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Renal Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 416. 3. A client with a diagnosis of cystitis has an indwelling urinary catheter and is being cared for by a nursing assistant. The nurse observes the nursing assistant care for the client and intervenes if the nursing assistant: 1. Uses soap and water to cleanse the perineal area 2. Keeps the urinary drainage bag below the level of the bladder 3. Uses the drainage tubing port to obtain urine samples 4. Lets the drainage tubing rest under the leg Answer: 4 Rationale: Proper care of an indwelling catheter is especially important to prevent prolonged infection or reinfection in the client with cystitis. The nurse and all caregivers must use strict aseptic technique when emptying the drainage bag or obtaining urine specimens. The perineal area is cleansed thoroughly using mild soap and water at least twice a day and following a bowel movement. The drainage bag is kept below the level of the bladder to prevent urine from being trapped in the bladder and, for the same reason, the drainage tubing is not placed under the client’s leg. The tubing must drain freely at all times. Test-Taking Strategy: Note the key word, intervenes. This word indicates a false response question and that you need to select the incorrect action. Eliminate option 1 first, because this is a basic standard of care for the client with an indwelling catheter. Option 3 is also consistent with principles of asepsis, and is eliminated next. From the remaining options, note that option 2 promotes drainage and option 4 could impede drainage. Review care of the client with an indwelling catheter if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Safe, Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Leadership/Management Reference: deWit, S. (2005). Fundamental concepts and skills for nursing. Philadelphia: W.B. Saunders, p. 550. 4. A nurse is assisting the client with cystitis with diet selection for an acid ash diet. The nurse encourages the client to eat which of the following foods? 1. Low-fat milk 2. Baked haddock 3. Garden peas 4. Apples Answer: 2 Rationale: Foods that are allowed on an acid ash diet include meat, fish, shellfish, cheese, eggs, poultry, grains, cranberries, prunes, plums, corn, lentils, and foods with high amounts of chlorine, phosphorus, and sulfur. Foods that not included are all milk and milk products (option 1); all other vegetables except corn and lentils (option 3); all fruits except cranberries, plums and

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prunes (option 4); and foods containing high amounts of sodium, potassium, calcium, and magnesium. Test-Taking Strategy: This question is difficult to answer without specific knowledge of the types of foods that may be included in the acid ash diet. Recalling that most fruits and vegetables are not included on the list may help you eliminate options 3 and 4. From the remaining options, it is necessary to know that foods such as meat, fish, cheese, and eggs are included, but milk and milk products are not. Review this diet if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Renal References: Nix, S. (2005). Williams basic nutrition and diet therapy (11th ed.). St. Louis: Mosby, pp. 406-407. Peckenpaugh, N. (2003). Nutrition essentials and diet therapy (9th ed.). Philadelphia: W.B. Saunders, p. 301. 5. A client who has a history of gout is also diagnosed with urolithiasis. The stones are determined to be of the uric acid type. The nurse tells the client to limit the intake of which food item? 1. Liver 2. Apples 3. Carrots 4. Milk Answer: 1 Rationale: Foods containing high amounts of purines should be avoided in the client with uric acid stones. This includes limiting or avoiding organ meats, such as liver, brain, heart, kidney, and sweetbreads. Other foods to avoid include herring, sardines, anchovies, meat extracts, consommés, and gravies. Foods that are low in purines include all fruits, many vegetables, milk, cheese, eggs, refined cereals, sugars and sweets, coffee, tea, chocolate, and carbonated beverages. Test-Taking Strategy: To answer this question, begin by examining the options and classifying the types of food sources they represent. Options 2 and 3 represent foods that are grown, whereas options 1 and 4 represent foods that derive from animal sources. Because purines are end products of protein metabolism, you would eliminate options 2 and 3 first. To select between options 1 and 4, you would need to know that organ meats such as liver provide more protein than milk. This will direct you to option 1. Review the foods that are high in purines if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Renal Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, p. 885.

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6. A nurse is caring for a client who has been diagnosed as having a kidney mass. The client asks the nurse the reason for a renal biopsy, when other tests such as computerized tomography (CT) and ultrasound are available. In formulating a response, the nurse incorporates the knowledge that a renal biopsy: 1. Helps differentiate between a solid mass and a fluid-filled cyst 2. Provides an outline of the renal vascular system 3. Gives specific cytological information about the lesion 4. Determines if the mass is growing rapidly or slowly Answer: 3 Rationale: Renal biopsy is a definitive test that gives specific information about whether the lesion is benign or malignant. An ultrasound discriminates between a fluid-filled cyst and a solid mass. Renal arteriography outlines the renal vascular system. Test-Taking Strategy: Use the process of elimination. Remember that with a biopsy the cells are examined under a microscope. This examination then yields specific information about the type of neoplastic cell. Review the purpose of this test if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Renal Reference: Pagana, K., & Pagana, T. (2003). Mosby’s diagnostic and laboratory test reference (6th ed.). St. Louis: Mosby, pp. 754-757. 7. A female client is admitted to the emergency room following a fall from a horse. The physician orders insertion of a Foley catheter. The nurse notes blood at the urinary meatus while preparing for the procedure. The nurse should: 1. Use extra povidone-iodine solution in cleansing the meatus. 2. Use a smaller catheter. 3. Administer pain medication before inserting the catheter. 4. Notify the physician. Answer: 4 Rationale: The presence of blood at the urinary meatus may indicate urethral trauma or disruption. The nurse notifies the physician, knowing that the client should not be catheterized until the cause of the bleeding is determined by diagnostic testing. Test-Taking Strategy: Focus on the data in the question, that the client experienced a traumatic injury. This will direct you to option 4. Review this procedure and the indications of urethral trauma if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Renal Reference: Christensen, B., & Kockrow, E. (2003). Foundations of nursing (4th ed.). St. Louis: Mosby, pp. 464-465. 8. A male client has a tentative diagnosis of urethritis. The nurse collects data from the client, knowing that which of the following are manifestations of the disorder?

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1. Hematuria and penile discharge 2. Hematuria and pyuria 3. Dysuria and proteinuria 4. Dysuria and penile discharge Answer: 4 Rationale: Urethritis in the male client often results from chlamydial infection and is characterized by dysuria, which is accompanied by a clear to mucopurulent discharge. Because this disorder often coexists with gonorrhea, diagnostic tests are done for both and include culture and rapid assays. Test-Taking Strategy: Use the process of elimination. Begin to answer this question by eliminating options 1 and 2. Urethritis is generally accompanied by dysuria in the male client. Knowing that the problem originates in the urethra, not the kidney, you would then eliminate the option with proteinuria, which indicates a problem with kidney function. This leaves option 4 as the correct option. The male client with urethritis has dysuria and discharge from the penis. Review the signs of urethritis if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Renal Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 769. 9. A nurse is assisting in planning a teaching session with the female client diagnosed with urethritis caused by infection with chlamydia. The nurse would plan to include which of the following points in the teaching session? 1. The most serious complication of this infection is sterility. 2. The infection can be prevented by using spermicide to alter the pH in the perineal area. 3. Medication therapy should be continued for 2 weeks without interruption. 4. Sexual partners during the last 12 months should be notified and treated. Answer: 1 Rationale: The most serious complication of chlamydial infection is sterility. The infection can be prevented by the use of latex condoms. It is treated with doxycycline for 7 days or with azithromycin (Zithromax) as a single dose. All sexual partners during the 30 days before diagnosis should be notified, examined, and treated as necessary. Test-Taking Strategy: Use the process of elimination. Eliminate option 2 first, using principles of infection control. Knowing that most courses of antibiotic therapy generally extend from 7 to 10 days may help you eliminate option 3 next. From the remaining options, it is necessary to know either that sterility is a serious and permanent complication or that sexual partners within the last month should be notified and treated as needed. Review the complications of this infection if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Adult Health/Renal References: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for

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positive outcomes (7th ed.). Philadelphia: W.B. Saunders, p. 1131. Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 996. 10. A male client who is hospitalized is diagnosed with urethritis caused by chlamydial infection. The nursing assistant assigned to the client asks the nurse what measures are necessary to prevent contraction of the infection during care. The nurse tells the assistant that: 1. Enteric precautions should be instituted for the client. 2. Contact isolation should be initiated, because the disease is highly contagious. 3. Standard precautions are sufficient, because the disease is transmitted sexually. 4. Gloves and mask should be used when in the client’s room. Answer: 3 Rationale: Chlamydia is a sexually transmitted disease, and is frequently called non-gonococcal urethritis in the male client. It requires no special precautions. Caregivers cannot acquire the disease during administration of care, and following universal precautions is the only measure that needs to be used. Test-Taking Strategy: A basic knowledge of infection control and disease transmission guides you to select option 3 as correct. Also, note that option 3 is the umbrella (global) option. If this question was difficult, review transmission of this disorder and standard precautions. Level of Cognitive Ability: Application Client Needs: Safe, Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Renal Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 139. 11. A client with chlamydial infection has received instructions on self-care and prevention of further infection. The nurse determines that the client needs further reinforcement if the client states that he or she will: 1. Reduce the chance of reinfection by limiting the number of sexual partners. 2. Use latex condoms to prevent disease transmission. 3. Return to the clinic as requested for follow-up culture in 1 week. 4. Use doxycycline prophylactically to prevent symptoms of chlamydia. Answer: 4 Rationale: Antibiotics are not taken prophylactically to prevent acquisition of urethritis from chlamydia. The risk of reinfection can be reduced by limiting the number of sexual partners, and by the use of condoms. In some instances, follow-up culture is requested in 4 to 7 days to confirm a cure. Test-Taking Strategy: Note the key words, needs further reinforcement. These words indicate a false response question and that you need to select the incorrect client statement. Options 1 and 2 are the most obviously correct and are therefore eliminated as possible answers to the question. From the remaining options, recalling the basic principles of antibiotic therapy allows you to eliminate option 4, because antibiotics are not used intermittently at random for prophylaxis of this infection. Review the client teaching points related to this infection if you had difficulty with this question.

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Level of Cognitive Ability: Comprehension Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Evaluation Content Area: Adult Health/Renal Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 998. 12. A nurse is caring for a client with epididymitis. The nurse anticipates noting which of the following findings on data collection? 1. Fever, diarrhea, groin pain, and ecchymosis 2. Fever, nausea and vomiting, and painful scrotal edema 3. Diarrhea, groin pain, and scrotal edema 4. Nausea, vomiting, and scrotal edema with ecchymosis Answer: 2 Rationale: Typical signs and symptoms of epididymitis include scrotal pain and edema, which are often accompanied by fever, nausea and vomiting, and chills. It is most often caused by infection, although sometimes it can be caused by trauma. It needs to be correctly distinguished from testicular torsion. Test-Taking Strategy: Use the process of elimination. Any disorder which ends in itis results from inflammation or infection. Therefore, an expected finding would be elevated temperature. With this in mind, you can eliminate options 3 and 4 because they do not contain fever as part of the option. From the remaining options, recalling that ecchymosis results from bleeding, which is not part of this clinical picture, directs you to option 2. Review the signs of this infection if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Renal Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 978. 13. A nurse is caring for the client with epididymitis. The nurse would avoid using which of the following treatment modalities in the care of the client? 1. Bed rest 2. Scrotal elevation 3. Sitz bath 4. Use of heating pad Answer: 4 Rationale: Common interventions used in the treatment of epididymitis include bed rest, elevation of the scrotum, ice packs, sitz baths, analgesics and antibiotics. A heating pad would not be used because direct application of heat could increase blood flow to the area and increase the swelling. Test-Taking Strategy: Note the key word, avoid. Eliminate options 1 and 2, because they are obviously the most helpful in the care of the client. Note that both remaining options address the application of heat to the client. A sitz bath uses a lower temperature and the heat is moist and

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soothing. Knowing that direct heat may increase inflammation with tissue that is already at risk will guide you to option 4 as the item to avoid. Review care of the client with epididymitis if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Renal Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 539. 14. A client has epididymitis as a complication of urinary tract infection. The nurse is giving the client instructions to prevent a recurrence. The nurse determines that the client needs further instruction if the client states to: 1. Drink increased amounts of fluids. 2. Continue to take antibiotics until all symptoms are gone. 3. Limit the force of the stream during voiding. 4. Use condoms to eliminate risk from chlamydia and gonorrhea. Answer: 2 Rationale: The client who experiences epididymitis from urinary tract infection (UTI) should increase intake of fluids to flush the urinary system. Because organisms can be forced into the vas deferens and epididymis from strain or pressure during voiding, the client may limit the force of the stream. Condom use can help prevent urethritis and epididymitis from sexually transmitted diseases. Antibiotics are always taken until the full course of therapy is completed. Test-Taking Strategy: Note the key words, needs further instruction. These words indicate a false response question and that you need to select the incorrect client statement. Because option 1 is consistent with good practices in the prevention of UTI, this option can be eliminated first. From the remaining options, it is necessary to know that the force of stream should be limited to prevent backflow into the epididymis, and that condoms are helpful in preventing this disorder from occurring as a complication of a sexually transmitted disease. Remember that antibiotics are not stopped when symptoms subside, but must be taken until the full course of therapy is completed. Review care of the client with epididymitis if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Evaluation Content Area: Adult Health/Renal Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 539. 15. A nurse is collecting data from a client who has had benign prostatic hyperplasia (BPH) in the past. To determine if the client is currently experiencing exacerbation of BPH, the nurse asks the client about the presence of which early symptom? 1. Urge incontinence 2. Nocturia 3. Decreased force of the stream of urine 4. Urinary retention

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Answer: 3 Rationale: Decreased force in the stream of urine is an early sign of BPH. The stream later becomes weak and dribbling. The client may then develop hematuria, frequency, urgency, urge incontinence, and nocturia. If untreated, complete obstruction and urinary retention can occur. Test-Taking Strategy: Note the key words, early symptom. Option 4 identifies the most severe of symptom and therefore is eliminated first. From the remaining options, focusing on the key words and recalling the pathophysiology related to BPH will direct you to option 3. Review the signs of benign prostatic hypertrophy if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Renal Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 978. 16. A client who has a cold is seen in the emergency room with inability to void. Because the client has a history of benign prostatic hyperplasia (BPH), the nurse questions the client about use of which medication? 1. Diuretics 2. Antibiotics 3. Antitussives 4. Decongestants Answer: 4 Rationale: In the client with BPH, episodes of urinary retention can be triggered by certain medications, such as decongestants, anticholinergics, and antidepressants. The client should be questioned about use of these medications if presenting with urinary retention. Retention can also be precipitated by other factors, such as alcoholic beverages, infection, bed rest, becoming chilled, and taking alcoholic beverages. Test-Taking Strategy: Use the process of elimination and focus on the issue, medications that could exacerbate or contribute to urinary retention in the client with BPH. Diuretics should help voiding; therefore, eliminate option 1. Next, eliminate option 2, because antibiotics should have no effect at all on voiding. From the remaining options, recall that medications that contain anticholinergics may cause urinary retention. This will guide you to option 4. Also, antitussives have no effect on urinary retention. Review the causes of urinary retention in the client with BPH if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Renal Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 978. 17. A client who had a prostatectomy has learned perineal exercises to gain control of the urinary sphincter. The nurse determines that the client needs further instruction if the client states that he or she will perform which of the following as part of these exercises? 1. Tightening the muscles as if trying to prevent urination

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2. Contracting the abdominal, gluteal and perineal muscles 3. Tightening the rectal sphincter while relaxing abdominal muscles 4. Performing the Valsalva maneuver Answer: 4 Rationale: The Valsalva maneuver is avoided following prostatectomy, because it increases the risk of bleeding in the postoperative period. An acceptable exercise is tightening the abdominal, gluteal, and perineal muscles, as if trying to prevent urination. Another acceptable exercise is tightening the rectal sphincter while relaxing the abdominal muscles; this prevents the Valsalva maneuver from occurring. Test-Taking Strategy: Note the key words, needs further instruction. These words indicate a false response question and that you need to select the incorrect client statement. Note that the type of movement in the exercises described in options 1, 2, and 3 are all muscle tightening types of movements. On the other hand, the Valsalva maneuver in option 4 involves bearing down or pushing types of movements. Review the purpose of perineal exercises if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Adult Health/Renal References: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, pp. 1025-1026. Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 982. 18. A nurse is working with the client newly diagnosed with chronic renal failure to set up a schedule for hemodialysis. The client states, “This is impossible! How can I even think about leading a normal life again if this is what I’m going to have to do?” The nurse determines that the client is exhibiting: 1. Withdrawal 2. Depression 3. Anger 4. Projection Answer: 3 Rationale: Psychosocial reactions to chronic renal failure and hemodialysis are varied, and may include anger. Other reactions include personality changes, emotional lability, withdrawal, and depression. The individual client’s response may vary depending on the client’s personality and support systems. The client in this question is exhibiting anger. The client has not projected blame on the nurse nor does the client statement reflect withdrawal or depression. Test-Taking Strategy: Use the process of elimination. Focusing on the client’s statement will direct you to option 3. Review the psychosocial aspects of care for the client with CRF if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Renal

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Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, pp. 788-789. 19. A client newly diagnosed with chronic renal failure has recently begun hemodialysis. Knowing that the client is at risk for disequilibrium syndrome, the nurse monitors the client during dialysis for: 1. Hypertension, tachycardia, and fever 2. Hypotension, bradycardia, and hypothermia 3. Restlessness, irritability, and generalized weakness 4. Headache, deteriorating level of consciousness, and twitching Answer: 4 Rationale: Disequilibrium syndrome is characterized by headache, mental confusion, decreasing level of consciousness, nausea, vomiting, twitching and possible seizure activity. It is caused by rapid removal of solutes from the body during hemodialysis. At the same time, the blood-brain barrier interferes with the efficient removal of wastes from brain tissue. As a result, water goes into cerebral cells because of the osmotic gradient, causing brain swelling and onset of symptoms. It most often occurs in clients who are new to dialysis, and is prevented by dialyzing for shorter times or at reduced blood flow rates. Test-Taking Strategy: Use the process of elimination. Noting the relation between the words “disequilibrium syndrome” and the signs in option 4 will direct you to this option. Review this syndrome if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Renal Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 784. 20. A client with chronic renal failure has been on dialysis for 3 years. The client is receiving the usual combination of medications for the disease, including aluminum hydroxide as a phosphate-binding agent. The client now presents with mental cloudiness, dementia, and complaints of bone pain. The nurse interprets that this data is compatible with: 1. Phosphate overdose 2. Aluminum intoxication 3. Advancing uremia 4. Folic acid deficiency Answer: 2 Rationale: Aluminum intoxication may occur when there is accumulation of aluminum, an ingredient in many phosphate-binding antacids. It results in mental cloudiness, dementia, and bone pain from infiltration of the bone with aluminum. This condition was formerly known as dialysis dementia. It may be treated with aluminum-chelating agents, which make aluminum available to be dialyzed from the body. It can be prevented by avoiding or limiting the use of phosphate-binding agents that contain aluminum. Test-Taking Strategy: Use the process of elimination. Note the relation between the medication name in the question and option 2. Review the signs of aluminum intoxication if you had

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difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Renal References: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, p. 958. McKenry, L., & Salerno, E. (2003). Mosby’s pharmacology in nursing (21st ed.). St. Louis: Mosby, p. 213. 21. A hemodialysis client with a left arm fistula is at risk for arterial steal syndrome. The nurse monitors this client for which manifestation of this disorder? 1. Warmth, redness, and pain in the left hand 2. Pallor, diminished pulse, and pain in the left hand 3. Edema and purplish discoloration of the left arm 4. Aching pain, pallor, and edema of the left arm Answer: 2 Rationale: Arterial steal syndrome results from vascular insufficiency after creation of a fistula. The client exhibits pallor and diminished pulse distal to the fistula and complains of pain distal to the fistula, which is caused by tissue ischemia. Warmth, redness, and pain would more likely characterize a problem with infection. Options 3 and 4 are not characteristics of steal syndrome. Test-Taking Strategy: Use the process of elimination. Recalling that arterial steal syndrome results from vascular insufficiency will direct you to option 2. Review these signs if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Renal Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, pp. 2097-2098. 22. A nurse is reviewing the medical record of a client with a diagnosis of pyelonephritis. Which disorder, if noted on the client’s record, would the nurse identify as a risk factor for this pyelonephritis? 1. Hypoglycemia 2. Coronary artery disease 3. Diabetes mellitus 4. Orthostatic hypotension Answer: 3 Rationale: Risk factors associated with pyelonephritis include diabetes mellitus, hypertension, chronic renal calculi, chronic cystitis, structural abnormalities of the urinary tract, presence of urinary stones, and indwelling or frequent urinary catheterization. Test-Taking Strategy: Use the process of elimination. Eliminate options 1 and 4 first as least likely being associated as risk factors. From the remaining options, remember that diabetes mellitus can cause renal complications. This will direct you to the correct option. Review these

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risk factors if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Renal Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 426. 23. A nurse is reviewing the client’s record and notes that the physician has documented that the client has a renal disorder. On review of the laboratory results, the nurse would most likely expect to note which of the following? 1. Elevated blood urea nitrogen (BUN) level 2. Decreased hemoglobin V 3. Decreased red blood cell (RBC) count 4. Decreased white blood cell (WBC)count Answer: 1 Rationale: BUN testing is a frequently used laboratory test to determine renal function. The BUN level starts to rise when the glomerular filtration rate falls below 40% to 60%. A decreased hemoglobin and RBC count may be noted if bleeding from the urinary tract occurs or if erythropoietic function by the kidney is impaired. An increased WBC is most likely to be noted in renal disease. Test-Taking Strategy: Use the process of elimination. Focus on the client’s diagnosis and note the key words, most likely expect to note. Eliminate option 4 first because it is not associated with the renal system. Although options 2 and 3 may be noted in some renal disorders, option 1 is the most likely laboratory finding. Remember, the BUN level is a frequently used laboratory test to determine renal function. Review the laboratory tests to determine renal function if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Renal Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 783. 24. Which of the following would the nurse include in the plan of care for a client following a renal scan? 1. Place the client on radiation precautions for 18 hours. 2. Save all urine in a radiation-safe container for 18 hours. 3. Limit contact with the client for 20 minutes per hour. 4. No special precautions required, except to wear gloves if coming in contact with the client’s urine. Answer: 4 Rationale: There are no specific precautions following a renal scan. The nurse wears gloves to maintain standard precautions. Options 1, 2, and 3 are unnecessary measures. Test-Taking Strategy: Use the process of elimination. Recalling that there is generally no danger

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from the small amount of radioactive material used in this procedure will direct you to option 4. Review this procedure if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Safe, Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Renal Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed.). Philadelphia: W.B. Saunders, pp. 964-965. 25. A client is scheduled for intravenous pyelography (IVP). Before the test, the priority nursing action would be to: 1. Administer an oral preparation of radiopaque dye. 2. Restrict fluids. 3. Determine a history of allergies. 4. Administer a sedative. Answer: 3 Rationale: The iodine-based dye used during the IVP can cause allergic reactions such as itching, hives, rash, tight feeling in the throat, shortness of breath, and bronchospasm. Assessing for allergies is the priority. Test-Taking Strategy: Note the key word, priority, and use the nursing process as a guide. Options 1, 2, and 4 address implementation. Option 3 is the only option that addresses data collection. Review this test if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Renal Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed.). Philadelphia: W.B. Saunders, p. 696. 26. Following a renal biopsy, the client complains of pain at the biopsy site, which radiates to the front of the abdomen. The nurse interprets this complaint and further monitors the client for: 1. Bleeding 2. Infection 3. Renal colic 4. Normal, expected pain Answer: 1 Rationale: If pain originates at the biopsy site and begins to radiate to the flank area and around the front of the abdomen, bleeding should be suspected. Hypotension, a decreasing hematocrit, and gross or microscopic hematuria would also indicate bleeding. Signs of infection would not appear immediately following a biopsy. Pain of this nature is not normal. There are no data to support the presence of renal colic. Test-Taking Strategy: Use the process of elimination. Focusing on the data in the question will assist in eliminating options 3 and 4. Recalling that signs of infection may not appear immediately following biopsy will assist in directing you to option 1 from the remaining options. Review the complications following renal biopsy if you had difficulty with this question.

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Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Renal Reference: Pagana, K., & Pagana, T. (2003). Mosby’s diagnostic and laboratory test reference (6th ed.). St. Louis: Mosby, p. 757. 27. A nurse is monitoring an 88-year-old woman suspected of having a urinary tract infection (UTI) for signs of the infection. Which of the following would alert the nurse to the possibility of the presence of a UTI? 1. Fever 2. Frequency 3. Confusion 4. Urgency Answer: 3 Rationale: In an older client, the only symptom of a UTI may be something a vague as increasing mental confusion or frequent unexplained falls. Frequency and urgency may commonly occur in an older client and fever can be associated with a variety of conditions. Test-Taking Strategy: Use the process of elimination. Note the client’s age in the question. Eliminate options 2 and 4 because they may commonly occur in an older client. Eliminate option 1 next, because fever can be associated with a variety of conditions. Review the clinical manifestations of UTI that occur in the older client if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Renal Reference: Potter, P., & Perry, A. (2005) Fundamentals of nursing (6th ed.). St. Louis: Mosby, p. 783. 28. A nurse is performing an admission assessment on a client with a diagnosis of bladder cancer. Which of the following would the nurse most likely expect to note on data collection of this client? 1. Hematuria 2. Burning 3. Urgency 4. Frequency Answer: 1 Rationale: Gross, painless hematuria is most frequently the first manifestation of bladder cancer. As the disease progresses the client may experience dysuria, frequency, and urgency. Test-Taking Strategy: Use the process of elimination and focus on the issue, a manifestation of bladder cancer. Eliminate options 2, 3, and 4 because they are common signs of a urinary tract infection. Review the specific manifestations associated with bladder cancer if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity

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Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Renal Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 778. 29. A client with benign prostatic hypertrophy (BPH) undergoes a transurethral resection of the prostate (TURP) and is receiving continuous bladder irrigations postoperatively. The nurse monitors the client for signs of transurethral resection syndrome. Which of the following data would indicate the onset of this syndrome? 1. Bradycardia and confusion 2. Tachycardia and diarrhea 3. Decreased urinary output and bladder spasms 4. Increased urinary output and anemia Answer: 1 Rationale: TUR syndrome is caused by increased absorption of nonelectrolyte irrigating fluid used during surgery. The client may show signs of cerebral edema and increased intracranial pressure such as increased blood pressure, bradycardia, confusion, disorientation, muscle twitching, visual disturbances, and nausea and vomiting. Test-Taking Strategy: Knowledge regarding TUR syndrome is required to answer this question. Recalling that increased intracranial pressure is the concern will direct you to option 1. Review this disorder if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Renal Reference: Phipps, W., Monahan, F., Sands, J., Marek, J., & Neighbors, M. (2003). Medicalsurgical nursing: Health and illness perspectives (7th ed.). St. Louis: Mosby, p. 1836. 30. A client with prostatitis secondary to kidney infection has received instructions on management of the condition at home and prevention of recurrence. The nurse determines that the client understood the instructions if the client has verbalized that he or she will: 1. Keep fluid intake to a minimum to decrease the need to void. 2. Exercise as much as possible to stimulate circulation. 3. Stop antibiotic therapy when pain subsides. 4. Use warm sitz baths and analgesics to increase comfort. Answer: 4 Rationale: Treatment of prostatitis includes medication with antibiotics, analgesics, and stool softeners. The client is also taught to rest, increase fluid intake, and use sitz baths for comfort. Antimicrobial therapy is always continued until the prescription is completely finished. Test-Taking Strategy: Use the process of elimination. Eliminate option 3 first, because stopping medication therapy before the end of the course is contraindicated. Option 1 is also eliminated, because fluid intake should be increased. From the remaining options, it is necessary to understand that sitz baths provide comfort and that rest is helpful in the healing process. Knowledge of either of these concepts will direct you to option 4. Review the measures to prevent prostatitis if you had difficulty with this question.

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Level of Cognitive Ability: Analysis Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Evaluation Content Area: Adult Health/Renal Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed.). St. Louis: Mosby, p. 1443. 31. A nurse is assessing the patency of an arteriovenous fistula in the left arm of a client who is receiving hemodialysis for the treatment of chronic renal failure. Which finding indicates that the fistula is patent? 1. Absence of a bruit on auscultation of the fistula 2. Palpation of a thrill over the fistula 3. Presence of a radial pulse in the left wrist 4. Capillary refill less than 3 seconds in the nail beds of the fingers on the left hand Answer: 2 Rationale: The nurse assesses the patency of the fistula by palpating for the presence of a thrill or auscultating for a bruit. The presence of a thrill and bruit indicate patency of the fistula. Although the presence of a radial pulse in the left wrist and capillary refill less than 3 seconds in the nail beds of the fingers on the left hand are normal findings, they do not assess fistula patency. Test-Taking Strategy: Use the process of elimination. Eliminate options 3 and 4 first because they are similar and assess for adequate circulation in the distal portion of the extremity (not the fistula). From the remaining options, focusing on the issue (patency) and noting the word “absence” in option 1 will assist in eliminating this option. Review the expected findings when assessing an arteriovenous fistula if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Renal Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed.). Philadelphia: W.B. Saunders, p. 1754. 32. A client newly diagnosed with renal failure will be receiving peritoneal dialysis. During the infusion of the dialysate, the client complains of abdominal pain. Which action by the nurse is appropriate? 1. Slow the infusion. 2. Decrease the amount to be infused. 3. Explain that the pain will subside after the first few exchanges. 4. Stop the dialysis. Answer: 3 Rationale: Pain during the inflow of dialysate is common during the first few exchanges because of peritoneal irritation; however, it disappears after a week or two. The infusion amount should not be decreased, and the infusion should not be slowed or stopped. Test-Taking Strategy: Use the process of elimination. Eliminate options 1, 2, and 4 because they are similar actions. Review the complications associated with peritoneal dialysis and the

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appropriate nursing actions, if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Renal Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed.). Philadelphia: W.B. Saunders, p. 1758. 33. The nurse is instructing a client with diabetes mellitus about peritoneal dialysis. The nurse tells the client that it is important to maintain the dwell time for the dialysis at the prescribed time because of the risk of: 1. Infection 2. Hyperglycemia 3. Fluid overload 4. Disequilibrium syndrome Answer: 2 Rationale: An extended dwell time increases the risk of hyperglycemia in the client with diabetes mellitus as a result of absorption of glucose from the dialysate and electrolyte changes. Diabetic clients may require extra insulin when receiving peritoneal dialysis. Options 1, 3, and 4 are not associated with dwell time. Test-Taking Strategy: Use the process of elimination. Noting the client’s diagnosis and recalling that the dialysate solution contains glucose will direct you to option 2. Review the complications associated with peritoneal dialysis if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Teaching/Learning Content Area: Adult Health/Renal Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed.). St. Louis: Mosby, p. 1232. 34. A client is diagnosed with polycystic kidney disease and the nurse provides information to the client about the treatment plan. The nurse determines that the client needs additional information if the client states that which of the following is a component of the treatment plan? 1. Sodium restriction 2. Antihypertensive medications 3. Increased water intake 4. Genetic counseling Answer: 1 Rationale: Individuals with polycystic kidney disease seem to waste rather than retain sodium. Thus, they need an increased sodium and water intake. Aggressive control of hypertension is essential. Genetic counseling is advisable because of the hereditary nature of the disease. Test-Taking Strategy: Note the key words, needs additional information. These words indicate a false response question and that you need to select the incorrect client statement. Recalling that sodium is wasted in polycystic kidney disease will direct you to option 1. Review the manifestations associated with this disease if you had difficulty with this question.

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Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Teaching/Learning Content Area: Adult Health/Renal Reference: Phipps, W., Monahan, F., Sands, J., Marek, J., & Neighbors, M. (2003). Medicalsurgical nursing: Health and illness perspectives (7th ed.). St. Louis: Mosby, p. 1204. 35. The client with chronic renal failure who is scheduled for hemodialysis this morning is due to receive a daily dose of enalapril (Vasotec). The nurse should plan to administer this medication: 1. Just prior to dialysis 2. During dialysis 3. On return from dialysis 4. The day after dialysis Answer: 3 Rationale: Antihypertensive medications such as enalapril are given to the client following hemodialysis. This prevents the client from becoming hypotensive during dialysis and from having the medication removed from the bloodstream by dialysis. There is no rationale for waiting a full day to resume the medication. This would lead to ineffective control of the blood pressure. Test-Taking Strategy: Use the process of elimination. Begin to answer this question by thinking about the effects of an antihypertensive medication on the blood pressure when fluid is being removed from the body. Because hypotension is much more likely to occur in this circumstance, eliminate options 1 and 2. Eliminate option 4 because this action would lead to ineffective blood pressure control. Review preprocedure hemodialysis measures if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Adult Health/Renal References: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed.). St. Louis: Mosby, p. 1222. Phipps, W., Monahan, F., Sands, J., Marek, J., & Neighbors, M. (2003). Medical-surgical nursing: Health and illness perspectives (7th ed.). St. Louis: Mosby, p. 766. <AQ>36. The nurse is monitoring a client receiving peritoneal dialysis and nurse notes that a client’s outflow is less than the inflow. Select the actions that the nurse should take. ____Place the client in a high-Fowler’s position. ____Check the level of the drainage bag. ____Contact the physician. ____Check the peritoneal dialysis system for kinks. ____Reposition the client to his or her side. Answers: Check the level of the drainage bag. Check the peritoneal dialysis system for kinks.

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Reposition the client to his or her side. Rationale: If outflow drainage is inadequate, the nurse attempts to stimulate outflow by changing the client’s position. Turning the client to the other side or making sure that the client is in good body alignment may assist with outflow drainage. A low-Fowler’s position reduces intra-abdominal pressure; increased intra-abdominal pressure also contributes to leakage at the peritoneal dialysis catheter site. The drainage bag needs to be lower than the client’s abdomen to enhance gravity drainage. The connecting tubing and the peritoneal dialysis system is also checked for kinks or twisting and the clamps on the system are checked to ensure that they are open. There is no reason to contact the physician. Test-Taking Strategy: Use the principles related to gravity flow and preventing obstruction to flow to answer this question. This will assist in determining the correct interventions. Review the nursing interventions related to insufficient flow of dialysate, if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Renal Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed.). Philadelphia: W.B. Saunders, p. 1759.

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