Nokea
A 56-year-old patient with cancer of the bladder is recovering from a cystectomy with an ileal conduit. Which aspect is an important nursing intervention of the patient with an ileal conduit?
- A. Instructing the patient to report mucus from the stoma
- B. Maintaining skin integrity
- C. Limiting oral intake to 1000 mL/day
- D. Limiting acid-ash foods
Correct Answer: B
Rationale: Care of the patient with an ileal conduit is a nursing challenge because of the continual drainage of urine through the stoma. Complications of this procedure are wound infection, dehiscence, and urinary leakage. Maintaining skin integrity reduces the risk of infection. Mucus draining from the stoma is expected, due to secretions from the intestine. The patient is urged to drink adequate fluids to flush the conduit. Limiting acid-ash foods benefits some patients with kidney stones.
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The nurse reassures the patient recovering from acute glomerulonephritis that after all other signs and symptoms of the disease subside, which change in the urine is normal?
- A. proteinuria.
- B. oliguria.
- C. hematuria.
- D. anasarca.
- E. oliguria.
Correct Answer: A,C
Rationale: Proteinuria and hematuria may exist microscopically even when other symptoms subside.
Which step is the second step of blood flow in order of flow through the nephron?
- A. Reabsorption in loop of Henle
- B. Efferent arteriole
- C. Filtration in the glomerulus
- D. Reabsorption in proximal convoluted tubule
- E. Afferent arteriole
- F. Secretion in the distal convoluted tubule
Correct Answer: C
Rationale: The blood enters the nephron via the afferent arteriole, is filtered through the glomerulus, reabsorption occurs in the proximal convoluted tubule, then the loop of Henle, then the distal convoluted tubule, and then out the efferent arteriole.
A patient who is receiving continuous bladder irrigation following a transurethral resection of the prostate (TURP) complains of 'spasm-like' pain over his lower abdomen. Which step will be the initial intervention by the nurse?
- A. Inform the nurse in charge.
- B. Decrease the continuous bladder irrigation flow.
- C. Administer the prescribed analgesic.
- D. Check the catheter and drainage system for obstruction.
Correct Answer: D
Rationale: The patient who has a TURP may have continuous closed bladder irrigation or intermittent irrigation to prevent occlusion of the catheter with blood clots, which would cause bladder spasms.
A patient, age 78, has been admitted to the hospital with dehydration and electrolyte imbalance. The patient is confused and incontinent of urine on admission. Which nursing intervention does the nurse expect to see in the plan of care?
- A. Restrict fluids after the evening meal.
- B. Insert an indwelling catheter.
- C. Assist the patient to the bathroom every 6 hours.
- D. Apply absorbent incontinence pads.
Correct Answer: D
Rationale: Use of protective undergarments may help to keep the patient and the patient's clothing dry. Patients who are confused are high risk for falls. Restricting fluids will only decrease incontinence during the night and will exacerbate the dehydration and electrolyte imbalance.
In the nephrotic syndrome, the glomeruli are damaged by inflammation and allow small ___ to pass through into the urine.
- A. proteins
Correct Answer: proteins
Rationale: In nephrotic syndrome, the glomeruli are damaged by inflammation and allow small proteins such as albumin to enter the urine. This creates a deficit of protein in the circulation volume (hypoalbuminemia), which leads to massive edema.