Nokea
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.
You may also like to solve these questions
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 caring for a patient with diabetic nephropathy who is scheduled for a right renal biopsy. Immediately after the biopsy, which of the following actions is essential?
- A. Monitor the blood urea nitrogen (BUN) and creatinine to assess renal function.
- B. Check blood glucose to assess for hyperglycemia or hypoglycemia.
- C. Insert a straight catheter to check for gross or microscopic hematuria.
- D. Apply a pressure dressing and keep the patient prone for 30-60 minutes.
Correct Answer: D
Rationale: After the procedure, a pressure dressing is applied, and the patient is kept prone for 30-60 minutes. Usually bed rest is prescribed for 24 hours. The blood glucose and BUN/creatinine will not be affected by the biopsy. Although monitoring for hematuria is needed, there is no need for catheterization.
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.
Which of the following explanations should the nurse provide to a patient who asks, 'What is a cystoscopy?'
- A. Your health care provider will insert a lighted tube into the bladder, and little catheters will be inserted through the tube into your kidney.
- B. Your health care provider will place a catheter into an artery in your groin and inject a dye that will visualize the blood supply to the kidneys.
- C. Your health care provider will inject a radioactive solution into a vein in your arm and the distribution of the isotope in your kidneys and bladder will be checked.
- D. Your health care provider will insert a lighted tube into the bladder through your urethra, inspect the bladder, and instill a dye that will outline your bladder on x-ray.
Correct Answer: D
Rationale: With a cystoscopy, a cystoscope is inserted into the bladder for direct visualization, and then contrast solution is injected through the scope so that x-rays can be taken. The response beginning, 'Your health care provider will place a catheter' describes a renal arteriogram procedure. The response beginning, 'Your health care provider will inject a radioactive solution' describes a nuclear scan. The response beginning, 'Your health care provider will insert a lighted tube into the bladder, and little catheters will be inserted' describes a retrograde pyelogram.
Which of the following actions should the nurse plan to take first when admitting a patient who has a history of neurogenic bladder as a result of a spinal cord injury?
- A. Ask about the usual urinary pattern and any measures used for bladder control.
- B. Assist the patient to the toilet at scheduled times to help ensure bladder emptying.
- C. Check the patient for urinary incontinence every 2 hours to maintain skin integrity.
- D. Use intermittent catheterization on a regular schedule to avoid the risk of infection.
Correct Answer: A
Rationale: Before planning any interventions, the nurse should complete the assessment and determine the patient's normal bladder pattern and the usual measures used by the patient at home. All the other responses may be appropriate, but until the assessment is complete, an individualized plan for the patient cannot be developed.