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When the nurse reviews the results of the client's urinalysis, which substance in the urine is most suggestive of a bladder infection?
- A. Glucose
- B. Blood
- C. Bilirubin
- D. Protein
Correct Answer: B
Rationale: Blood in the urine (hematuria) is a common sign of a bladder infection due to inflammation and irritation of the bladder lining.
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The nurse is preparing a plan of care for the client diagnosed with acute glomerulonephritis. Which statement is an appropriate long-term goal?
- A. The client will have a blood pressure within normal limits.
- B. The client will show no protein in the urine.
- C. The client will maintain normal renal function.
- D. The client will have clear lung sounds.
Correct Answer: C
Rationale: Maintaining normal renal function is the ultimate long-term goal for acute glomerulonephritis, as it indicates resolution of renal damage. Normal BP and no proteinuria are intermediate goals, and clear lung sounds are unrelated.
The nurse is caring for a client with chronic pyelonephritis. Which assessment data support the diagnosis of chronic pyelonephritis?
- A. The client has fever, chills, flank pain, and dysuria.
- B. The client complains of fatigue, headaches, and increased urination.
- C. The client had a group B beta-hemolytic strep infection last week.
- D. The client has an acute viral pneumonia infection.
Correct Answer: B
Rationale: Chronic pyelonephritis presents with subtle symptoms like fatigue, headaches, and polyuria due to long-term renal damage. Acute symptoms (fever, chills) are more typical of acute pyelonephritis. Strep or pneumonia are unrelated.
As the nurse instructs the client about CBI, which information should the nurse provide? Select all that apply.
- A. You may feel the urge to urinate even though the bladder is empty.
- B. Do not to try to urinate around the catheter, because this will cause bladder spasms.
- C. You need to limit your fluids to 4 glasses per day.
- D. It is normal for the urine to be bloody immediately after surgery.
- E. The catheter will be removed in about a week.
- F. By the time you are ready to go home, your urine should be pink with a few clots.
Correct Answer: A,B,D,F
Rationale: These statements accurately describe CBI effects, expectations, and precautions post-TURP.
Postoperatively, which assessment finding is most suggestive that the client is hemorrhaging?
- A. Acute flank pain
- B. Abdominal distention
- C. Flushed, warm skin
- D. Nausea and vomiting
Correct Answer: B
Rationale: Abdominal distention may indicate internal bleeding, a critical sign of hemorrhage post-nephrectomy.
The client is admitted to the emergency department after a gunshot wound to the abdomen. Which nursing intervention should the nurse implement first to prevent ARF?
- A. Administer normal saline IV.
- B. Take vital signs.
- C. Place client on telemetry.
- D. Assess abdominal dressing.
Correct Answer: A
Rationale: A gunshot wound can cause hypovolemia, leading to prerenal ARF. Administering normal saline IV restores volume and perfusion, preventing ARF. Vital signs, telemetry, and dressing assessment are important but secondary to fluid resuscitation.