Nokea
A patient's urine dipstick indicates a small amount of protein in the urine. Which of the following actions should the nurse take next?
- A. Check which medications the patient is currently taking.
- B. Obtain a clean-catch urine specimen for culture and sensitivity testing.
- C. Ask the patient about any family history of persistent renal failure.
- D. Send a urine specimen to the laboratory to test for ketones and glucose.
Correct Answer: A
Rationale: Normally the urinalysis will show zero to trace amounts of protein, but some medications may give false-positive readings. The other actions by the nurse may be appropriate, but checking for medications that may affect the dipstick accuracy should be done first.
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The nurse is admitting an older-adult patient with benign prostatic hyperplasia. Which of the following actions should be included in the nursing plan of care?
- A. Limit fluid intake to no more than 1500 mL/day.
- B. Leave a light on in the bathroom during the night
- C. Pad the patient's bed to accommodate overflow incontinence.
- D. Ask the patient to use a urinal so that all urine can be measured.
Correct Answer: B
Rationale: The patient's age and diagnosis indicate a likelihood of nocturia, so leaving the light on in the bathroom is appropriate. Fluids should be encouraged because dehydration is more common in older patients. The information in the question does not indicate that measurement of the patient's output is necessary or that the patient has overflow incontinence.
The nurse is caring for a patient following an intravenous pyelogram (IVP) and obtains all of the following assessment data. Which of the following findings require immediate action by the nurse?
- A. The heart rate is 58 beats/minute.
- B. The respiratory rate is 38 breaths/minute.
- C. The patient complains of a dry mouth.
- D. The urine output is 400 mL in the first 2 hours.
Correct Answer: B
Rationale: The increased respiratory rate indicates that the patient may be experiencing an allergic reaction (anaphylactic reaction) to the contrast medium used during the procedure. The nurse should immediately assess the patient's oxygen saturation and breath sounds. The other data are not unusual findings following an IVP.
The nurse is assessing a patient's urinary system and is unable to palpate either kidney. Which of the following actions should the nurse take next?
- A. Obtain a urine specimen to check for hematuria
- B. Document the information on the assessment form.
- C. Ask the patient about any history of recent sore throat.
- D. Ask the health care provider about scheduling a renal ultrasound.
Correct Answer: B
Rationale: The kidneys are protected by the abdominal organs, ribs, and muscles of the back and may not be palpable under normal circumstances, so no action except to document the assessment information is needed. Asking about a recent sore throat, checking for hematuria, or obtaining a renal ultrasound may be appropriate when assessing for renal problems for some patients, but there is nothing in the question stem to indicate that they are appropriate for this patient.
For which of the following purposes does the nurse use auscultation during assessment of the urinary system?
- A. Check for ureteral peristalsis.
- B. Assess for bladder distension.
- C. Identify renal artery or aortic bruits.
- D. Determine the position of the kidneys.
Correct Answer: C
Rationale: The presence of a bruit may indicate problems such as renal artery tortuosity or abdominal aortic aneurysm. Auscultation would not be helpful in assessing for the other listed urinary tract information.
The health care provider orders a clean-catch urine specimen for culture and sensitivity testing for a patient with a suspected urinary tract infection (UTI). Which of the following actions should the nurse implement to obtain the specimen?
- A. Teach the patient to clean the urethral area, void a small amount into the toilet, and then void into a sterile specimen cup.
- B. Have the patient empty the bladder completely, and then obtain the next urine specimen that the patient is able to void.
- C. Insert a short, small 'mini' catheter attached to a collecting container into the urethra and bladder to obtain the specimen.
- D. Clean the area around the meatus with a povidone-iodine swab, and then have the patient void into a sterile container.
Correct Answer: A
Rationale: Teach the patient to clean the urethral area, void a small amount into the toilet, and then void into a sterile specimen cup best describes the technique for obtaining a clean-catch specimen. The answer beginning, 'insert a short, small, 'mini' catheter attached to a collecting container' describes a technique that would result in a sterile specimen, but a health care provider's order for a catheterized specimen would be required. Using povidone-iodine before obtaining the specimen is not necessary and might result in suppressing the growth of some bacteria. And the technique described in the answer beginning 'have the patient empty the bladder completely' would not result in a sterile specimen.