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A patient has been admitted to the medical unit with a diagnosis of ureteral colic secondary to urolithiasis. When planning the patients admission assessment, the nurse should be aware of the signs and symptoms that are characteristic of this diagnosis? Select all that apply.
- A. Diarrhea
- B. High fever
- C. Hematuria
- D. Urinary frequency
- E. Acute pain
Correct Answer: C,D,E
Rationale: Stones lodged in the ureter (ureteral obstruction) cause acute, excruciating, colicky, wavelike pain, radiating down the thigh and to the genitalia. Often, the patient has a desire to void, but little urine is passed, and it usually contains blood because of the abrasive action of the stone. This group of symptoms is called ureteral colic. Diarrhea is not associated with this presentation and a fever is usually absent due to the noninfectious nature of the health problem.
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An adult patient has been hospitalized with pyelonephritis. The nurses review of the patients intake and output records reveals that the patient has been consuming between3 \mathrm{~L}$ and3.5 \mathrm{~L}$ of oral fluid each day since admission. How should the nurse best respond to this finding?
- A. Supplement the patients fluid intake with a high-calorie diet.
- B. Emphasize the need to limit intake to2 \mathrm{~L}$ of fluid daily.
- C. Obtain an order for a high-sodium diet to prevent dilutional hyponatremia.
- D. Encourage the patient to continue this pattern of fluid intake.
Correct Answer: D
Rationale: Unless contraindicated, 3 to4 \mathrm{~L}$ of fluids per day is encouraged to dilute the urine, decrease burning on urination, and prevent dehydration. No need to supplement this fluid intake with additional calories or sodium.
The nurse is assessing a patient admitted with renal stones. During the admission assessment, what parameters would be priorities for the nurse to address? Select all that apply.
- A. Dietary history
- B. Family history of renal stones
- C. Medication history
- D. Surgical history
- E. Vaccination history
Correct Answer: A,B,C
Rationale: Dietary and medication histories and family history of renal stones are obtained to identify factors predisposing the patient to stone formation. When caring for a patient with renal stones it would not normally be a priority to assess the vaccination history or surgical history, since these factors are not usually related to the etiology of kidney stones.
A 52-year-old patient is scheduled to undergo ileal conduit surgery. When planning this patients discharge education, what is the most plausible nursing diagnosis that the nurse should address?
- A. Impaired mobility related to limitations posed by the ileal conduit
- B. Deficient knowledge related to care of the ileal conduit
- C. Risk for deficient fluid volume related to urinary diversion
- D. Risk for autonomic dysreflexia related to disruption of the sacral plexus
Correct Answer: B
Rationale: The patient will most likely require extensive teaching about the care and maintenance of a new urinary diversion. A diversion does not create a serious risk of fluid volume deficit. Mobility is unlikely to be impaired after the immediate postsurgical recovery. The sacral plexus is not threatened by the creation of a urinary diversion.
A patient with a recent history of nephrolithiasis has presented to the ED. After determining that the patients cardiopulmonary status is stable, what aspect of care should the nurse prioritize?
- A. IV fluid administration
- B. Insertion of an indwelling urinary catheter
- C. Pain management
- D. Assisting with aspiration of the stone
Correct Answer: C
Rationale: The patient with kidney stones is often in excruciating pain, and this is a high priority for nursing interventions. In the short term, this would supersede the patients need for IV fluids or for catheterization. Kidney stones cannot be aspirated.
A nurse who provides care in a long-term care facility is aware of the high incidence and prevalence of urinary tract infections among older adults. What action has the greatest potential to prevent UTIs in this population?
- A. Administer prophylactic antibiotics as ordered.
- B. Limit the use of indwelling urinary catheters.
- C. Encourage frequent mobility and repositioning.
- D. Toilet residents who are immobile on a scheduled basis.
Correct Answer: B
Rationale: When indwelling catheters are used, the risk of UTI increases dramatically. Limiting their use significantly reduces an older adults risk of developing a UTI. Regular toileting promotes continence, but has only an indirect effect on the risk of UTIs. Prophylactic antibiotics are not normally administered. Mobility does not have a direct effect on UTI risk.