Nokea
After receiving change-of-shift report, which of the following patients should the nurse assess first?
- A. A patient with nephrotic syndrome with a urinary output of 3000 mL yesterday
- B. A patient with urolithiasis who has not voided for 6 hours
- C. A patient with stage 3 chronic kidney disease who needs patient teaching
- D. A patient with stage 4 chronic kidney disease with complaints of dysuria
Correct Answer: B
Rationale: A patient with urolithiasis who has not voided for 6 hours is at risk for urinary obstruction, which can lead to hydronephrosis or renal damage, requiring immediate assessment. The other patients' conditions are less urgent; high urine output, dysuria, and teaching needs do not indicate immediate risk.
You may also like to solve these questions
A patient who has had a transurethral resection with fulguration for bladder cancer 3 days previously calls the nurse at the urology clinic. Which of the following information given by the patient is most important to report to the health care provider?
- A. The patient is using opioids for pain.
- B. The patient has noticed clots in the urine.
- C. The patient is very anxious about the cancer.
- D. The patient is taking a 15-minute sitz bath twice a day.
Correct Answer: B
Rationale: Clots in the urine are not expected and require further follow-up. Sitz baths two to three times a day, use of opioids for pain, and anxiety are typical after this procedure.
The nurse is caring for a patient who has bladder cancer and had a cystectomy with creation of an Indiana pouch. Which of the following topics should the nurse include in patient teaching?
- A. Application of ostomy appliances
- B. Catheterization technique and schedule
- C. Analgesic use before emptying the pouch
- D. Use of barrier products for skin protection
Correct Answer: B
Rationale: The Indiana pouch enables the patient to self-catheterize every 4-6 hours. There is no need for an ostomy device or barrier products. Catheterization of the pouch is not painful.
The nurse is teaching a patient about avoiding the recurrence of a urinary tract infection. Which of the following information should be included in the teaching plan?
- A. Teach the patient to wipe from back to front after voiding.
- B. Suggest the use of a diaphragm during intercourse.
- C. Advise the patient to urinate every 2-4 hours during the day.
- D. Advise the patient to report cloudy urine.
- E. Educate about the effects of a bubble bath.
Correct Answer: C,D,E
Rationale: The nurse would teach about voiding every 2-4 hours during the day, avoiding bubble baths, and advising the patient to report cloudy urine, as well as pain, frequency, and urgency. The patient should be taught to wipe from front to back. Diaphragm use should be discouraged temporarily, rather than suggested as an option.
Which of the following nursing actions is most helpful in decreasing the risk for hospital-acquired infection (HAI) of the urinary tract in patients admitted to the hospital?
- A. Avoid unnecessary catheterizations
- B. Encourage adequate oral fluid intake.
- C. Test urine with a dipstick daily for nitrites.
- D. Provide thorough perineal hygiene to patients.
Correct Answer: A
Rationale: Since catheterization bypasses many of the protective mechanisms that prevent urinary tract infection (UTI), avoidance of catheterization is the most effective means of reducing HAI. The other actions will also be helpful, but are not as useful as decreasing urinary catheter use.
The nurse is providing teaching to a patient with impaired urinary elimination related to an UTI who weighs 70 kg. Which of the following daily fluid intake amounts should the nurse include in the teaching plan?
- A. 650 mL
- B. 1250 mL
- C. 1800 mL
- D. 2450 mL
Correct Answer: C
Rationale: The recommended daily liquid intake for the ambulatory adult is approximately 30 mL/kg body weight per day. Thus, a 70-kg person would require approximately 2100 mL each day. Among the options, 1800 mL is the closest appropriate amount to promote adequate urine output and prevent UTI recurrence.