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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.
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The nurse is caring for a client who is describing urinary symptoms of needing to go to the bathroom with little notice. When the nurse is documenting these symptoms, which medical term will the nurse document?
- A. Urinary frequency
- B. Urinary urgency
- C. Urinary incontinence
- D. Urinary stasis
Correct Answer: B
Rationale: The nurse would document urinary urgency. Urinary frequency is urinating more frequently than normal often times due to inadequate emptying of the bladder. Urinary incontinence is the involuntary loss of urine. Urinary stasis is a stoppage or diminution of flow.
The nurse is instructing a 3-year-old's parent regarding abnormal findings within the urinary system. Which assessment finding would the nurse document as a normal finding for this age group?
- A. Dysuria
- B. Enuresis
- C. Hematuria
- D. Anuria
Correct Answer: B
Rationale: The nurse would be most correct to document that enuresis, the involuntary voiding during sleep or commonly called 'wetting the bed,' is a normal finding in a pediatric client younger than 5 years old. Dysuria (pain on urination), hematuria (red blood cell in urine), and anuria (urine output less than 50 mL/day) are all abnormal findings needing further investigation.
The nurse has received morning lab work on a client with chronic renal disease. Which finding indicates renal disease?
- A. Urine pH of 6.5
- B. Urine nitrate: negative
- C. Protein level of 400 mg/dL
- D. Specific gravity: 1.0.2
Correct Answer: C
Rationale: The nurse must analyze components of a urinalysis to determine abnormal results. Protein at a level of 400 mg/dL is high and indicates renal disease. The other results are normal.
The nurse is caring for an 84-year-old client who is being admitted for diagnostic studies for a potential renal disorder. The nurse planning care has initiated a care plan of 'knowledge deficiency related to poor understanding of diagnostic studies as manifested by client statements of not understanding diagnostic procedures and elevated anxiety.' Which nursing intervention(s) does the nurse include in the plan of care?
- A. Assess client's level of understanding.
- B. Provide written reading material.
- C. Remain with client and answer questions.
- D. Administer an ordered sedative.
- E. Use simple language.
- F. Direct instruction to family.
Correct Answer: A,C,D,E
Rationale: The nurse is caring for a client who is unsure of the diagnostic study and is anxious. The nursing interventions to assist the client begin with understanding knowledge base following an assessment of understanding. Next, remaining with client and answering questions in simple terms alleviates anxiety and opens teaching and communication. If all consents are signed, an ordered sedative may diminish client anxiety. Providing written material at this time is not helpful and may increase anxiety. All instruction should be primarily directed toward the client but include all family members.
The nurse is caring for a client who has a history of urine reflux. To assess the client for this urinary complication, which nursing action is best?
- A. Ask the client if voiding sufficient quantities has been a problem.
- B. Monitor the client's intake and output for inconsistency.
- C. Have the client void into a collection device.
- D. Palpate the client's bladder for distension.
Correct Answer: D
Rationale: Normally, urine flows in one direction because of peristaltic action and because the ureters enter the bladder at an oblique angle. The reflux of urine (urine that flows backward) can occur secondary to a distended bladder. By palpating for bladder distension, the nurse is able to determine that reflux urine traveled back to the bladder instead of traveling from the bladder down the urethra. All of the other options provide data that can be helpful, but actually feeling for the distension is best. Using a bladder scanner would also provide an amount of urine in the bladder.