Nokea
A gerontologic consideration of aging is the decreased ability to concentrate urine. This consideration leads to an increased susceptibility to dehydration further complicated by a deficit in thirst. Which nursing action would be most appropriate to address this concern?
- A. Encourage the client to decrease fluid intake.
- B. Instruct the client to double void.
- C. Offer the client use of the bathroom.
- D. Monitor the client for signs of drug toxicity.
Correct Answer: C
Rationale: A dull sound when percussing over the bladder indicates a full bladder. Because the bladder is full, the nurse would offer the client use of the bathroom. Tenderness over the kidney can indicate an infection or stones. Bruits are an abnormal vascular sound that does not indicate the need to use the bathroom. Ingesting water does not mean that the client has to void at this time.
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The nurse is caring for a client who is admitted to the nursing unit for a biopsy of the urinary tract tissue. When planning nursing care for the postoperative period, which nursing intervention documents the prescribed activity level?
- A. Maintain the client on bedrest
- B. Assist the client for bathroom privileges
- C. Ambulate the client in the hall
- D. Activity as tolerated
Correct Answer: A
Rationale: Following a urinary tract biopsy, the client is typically maintained on bedrest to minimize the risk of bleeding, given the high vascularity of the renal system. Assisting with bathroom privileges, ambulating in the hall, or allowing activity as tolerated may increase the risk of complications such as bleeding and are not typically prescribed immediately post-procedure.
The nurse is caring for a client who has presented to the walk-in clinic. The client verbalizes pain on urination, feelings of fatigue, and diffuse back pain. When completing a head-to-toe assessment, at which specific location would the nurse assess the client's kidneys for tenderness?
- A. The upper abdominal quadrants on the left and right side
- B. The costovertebral angle
- C. Above the symphysis pubis
- D. Around the umbilicus
Correct Answer: B
Rationale: The nurse is correct to assess the kidneys for tenderness at the costovertebral angle. The other options are incorrect.
A client has a full bladder. Which sound would the nurse expect to hear on percussion?
- A. Tympany
- B. Dullness
- C. Resonance
- D. Flatness
Correct Answer: B
Rationale: Dullness on percussion indicates a full bladder; tympany indicates an empty bladder. Resonance is heard over areas that are part air and part solid, such as the lungs. Flatness is heard over very dense tissue, such as the bone or muscle.
The nurse at the diabetes clinic is instructing a client who is struggling with compliance to the diabetic diet. When discussing disease progression, which manifestation of the disease process on the urinary system is most notable?
- A. Clients have frequent urinary tract infections.
- B. Clients develop a neurogenic bladder.
- C. Clients have urinary frequency.
- D. Clients have chronic renal failure.
Correct Answer: D
Rationale: Although all of the options may occur in the client with diabetes mellitus, the option which is most notable, and potentially life threatening, is chronic renal failure.
The nurse is assessing a client at the diagnostic imaging center. For which diagnostic test would the client be assessed for an allergy to iodine?
- A. Uroflowmetry
- B. Computed tomography with contrast
- C. Cystoscopy
- D. Bladder ultrasonography
Correct Answer: B
Rationale: The nurse is correct to assess for an allergy to iodine when a computed tomography with contrast medium is prescribed. Uroflowmetry, cystoscopy, and bladder ultrasonography are performed without the use of contrast medium.