Nokea
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.
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The nurse is reviewing a patient's chart and notes that the patient has dysuria. To assess whether there is any improvement, which of the following questions should the nurse ask?
- A. Do you have any blood in your urine?
- B. Do you have to urinate very frequently?
- C. Do you have any pain when you urinate?
- D. Do you have to get up at night to urinate?
Correct Answer: C
Rationale: Dysuria is painful urination. The alternate responses are used to assess other urinary tract symptoms: hematuria, nocturia, and frequency.
During assessment of a patient with decreased renal function, which of the following medications taken by the patient at home is of most concern to the nurse?
- A. Ibuprofen
- B. Warfarin
- C. Folic acid
- D. Penicillin
Correct Answer: A
Rationale: The nonsteroidal anti-inflammatory drugs (NSAIDs) are nephrotoxic and should be avoided in patients with impaired renal function. The nurse also should ask about reasons the patient is taking the other medications, but the medication of most concern is the ibuprofen.
The nurse is reviewing the results of a patient's urinalysis. Which of the following information indicates that the nurse should notify the health care provider?
- A. pH 6.2
- B. Trace protein
- C. WBC: 20-26/hpf
- D. Specific gravity: 1.021
Correct Answer: C
Rationale: The increased number of white blood cells (WBCs) indicates the presence of urinary tract infection or inflammation. Normal WBC result in a urinalysis report is 0-5/hpf. The other findings are normal.
Which of the following techniques should the nurse use to assess the flank area of a patient with pyelonephritis for tenderness?
- A. Push gently into the two lowest intercostal spaces.
- B. Palpate along both sides of the lumbar vertebral column.
- C. Position one hand flat at the costovertebral angle (CVA) and strike it with the other fist.
- D. Use two fingers to percuss the area between the iliac crest and ribs along the midaxillary line.
Correct Answer: C
Rationale: Checking for flank pain is best performed by percussion of the CVA and asking about pain. The other techniques would not assess for flank pain.
A patient who had a cystoscopy the previous day calls the urology clinic and gives the nurse all the following information. Which of the following patient statements should be reported immediately to the health care provider?
- A. My urine still looks pink.
- B. My IV site is still bruised.
- C. I have a temperature of 38.3°C (100.9°F).
- D. I did not sleep well last night.
Correct Answer: C
Rationale: The patient's elevated temperature may indicate a bladder infection, a possible complication of cystoscopy. The health care provider should be notified so that antibiotic therapy can be started. Pink-tinged urine is expected after a cystoscopy. The insomnia and bruising should be discussed further with the patient but do not indicate a need to notify the health care provider.