Nokea
The nurse is caring for a patient with benign prostatic hyperplasia who has chills, fever, and is vomiting. Which of the following findings by the nurse is most helpful in determining whether the patient has an upper urinary tract infection (UTI)?
- A. Suprapubic pain
- B. Bladder distention
- C. Foul-smelling urine
- D. Costovertebral tenderness
Correct Answer: D
Rationale: Costovertebral tenderness is characteristic of pyelonephritis. The other symptoms are characteristic of lower UTI and are likely to be present if the patient also has an upper UTI.
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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.
The nurse is caring for a patient who is two days postoperative with an ileal conduit, and the patient will not look at the stoma or participate in care and insists that no one but the ostomy nurse specialist care for the stoma. Which of the following nursing diagnoses best reflects the data that the nurse has obtained?
- A. Anxiety related to threat to current status (effects of procedure on lifestyle)
- B. Disturbed body image related to alteration in self-perception
- C. Ineffective coping related to insufficient sense of control
- D. Ineffective denial related to ineffective coping strategies (denial of altered body function)
Correct Answer: B
Rationale: The patient's unwillingness to look at the stoma or participate in care indicates that disturbed body image is the best diagnosis. No data suggest that the impact on lifestyle is a concern for the patient, or that ineffective coping is a result of an insufficient sense of control. The patient's insistence that only the ostomy nurse care for the stoma indicates that denial is not present.
A patient returns to the clinic with recurrent dysuria after being treated with trimethoprim-sulfamethoxazole for 3 days. Which of the following actions should the nurse plan to take?
- A. Remind the patient about the need to drink 1000 mL of fluids daily.
- B. Obtain a midstream urine specimen for culture and sensitivity testing.
- C. Teach the patient to take the prescribed trimethoprim-sulfamethoxazole for at least 3 more days.
- D. Suggest that the patient drink cranberry juice to treat the symptoms.
Correct Answer: B
Rationale: Since uncomplicated urinary tract infections (UTIs) are usually successfully treated with 3 days of antibiotic therapy, this patient will need a urine culture and sensitivity to determine appropriate antibiotic therapy. Although daily intake of cranberry juice has been purported to assist in treating, there is currently no conclusive evidence to support advocating this treatment. The fluid intake should be increased to at least 1000 mL/day. Since the UTI has persisted after treatment with trimethoprim-sulfamethoxazole, the patient is likely to need a different antibiotic.
The nurse observes an unregulated care provider (UCP) taking the following actions when caring for a patient with an indwelling catheter. Which of the following actions requires the nurse to intervene?
- A. Taping the catheter to the skin on the patient's upper inner thigh
- B. Cleaning around the patient's urinary meatus with soap and water
- C. Using alcohol-based hand cleaner before handling the catheter
- D. Disconnecting the catheter from the drainage tube to obtain a specimen
Correct Answer: D
Rationale: The catheter should not be disconnected from the drainage tube because this increases the risk for urinary tract infection (UTI). The other actions are appropriate and do not require any intervention.
The nurse is caring for a patient who has had left-sided extracorporeal shock wave lithotripsy. Which of the following findings is most important to report?
- A. Blood in urine
- B. Left flank pain
- C. Left flank bruising
- D. Drop in urine output
Correct Answer: D
Rationale: A drop in urine output after lithotripsy may indicate obstruction or renal damage, which is a critical complication requiring immediate reporting. Hematuria, left flank pain, and bruising are common post-lithotripsy findings and are less urgent unless severe or persistent.