Nokea
Which assessment finding for a patient who has just been admitted with acute pyelonephritis is most important for the nurse to report to the health care provider?
- A. Foul-smelling urine
- B. Complaint of flank pain
- C. Blood pressure 88/45 mm Hg
- D. Temperature 37.8°C (100°F)
Correct Answer: C
Rationale: Low blood pressure (88/45 mm Hg) indicates potential septic shock, a life-threatening complication of pyelonephritis, requiring urgent intervention. Foul-smelling urine, flank pain, and a mild fever are common findings in pyelonephritis but are less critical unless accompanied by systemic signs like hypotension.
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The nurse is admitting a patient with new onset nephrotic syndrome. Which of the following findings should the nurse expect to assess related to this illness?
- A. Poor skin turgor
- B. High urine ketones
- C. Recent weight gain
- D. Low blood pressure
Correct Answer: C
Rationale: The patient with a nephrotic syndrome will have weight gain associated with edema. Hypertension is a clinical manifestation of nephrotic syndrome. Skin turgor is normal because of the edema. Urine protein is high.
Which of the following findings for a patient who has had a cystectomy with an ileal conduit the previous day is most important for the nurse to communicate to the health care provider?
- A. Cloudy appearing urine
- B. Hypotonic bowel sounds
- C. Heart rate 102 beats/minute
- D. Stoma appears pale and dry
Correct Answer: D
Rationale: A pale and dry stoma indicates poor vascularity or ischemia, which is a critical complication requiring immediate reporting to the health care provider. Cloudy urine, hypotonic bowel sounds, and a slightly elevated heart rate are common postoperative findings but are less urgent unless accompanied by other critical symptoms.
The nurse is caring for a female patient who has had a urinary tract infection (UTI). Which of the following interventions should the nurse include in the plan of care?
- A. Encourage the patient to use a diaphragm for contraception.
- B. Sitz baths
- C. Encourage the patient to drink cranberry juice.
- D. Teach the patient how to do isometric perineal exercises.
Correct Answer: B
Rationale: Sitz baths can soothe the perineal area and promote voiding in patients with a UTI. Diaphragm use increases the risk for UTI and should be avoided. While cranberry juice may help prevent UTIs, evidence is inconclusive, and it is not a priority intervention. Isometric perineal exercises (e.g., Kegel exercises) are useful for stress incontinence, not UTI management.
The nurse is caring for a patient who has had an ureterolithotomy with a left ureteral catheter and a urethral catheter in place. Which of the following actions should the nurse include in the plan of care?
- A. Provide education about home care for both catheters
- B. Apply continuous steady tension to the ureteral catheter.
- C. Clamp the ureteral catheter unless output from
- D. Call the health care provider if the ureteral catheter output drops suddenly.
Correct Answer: D
Rationale: The health care provider should be notified if the ureteral catheter output decreases since obstruction of this catheter may result in an increase in pressure in the renal pelvis. Tension on the ureteral catheter should be avoided in order to prevent catheter displacement. To avoid pressure in the renal pelvis, the catheter is not clamped. Since the patient is not usually discharged with a ureteral catheter in place, patient teaching about both catheters is not needed.
The nurse is caring for a patient with renal calculi, gross hematuria, and severe colicky left flank pain. Which of the following actions is priority at this time?
- A. Encourage oral fluid intake.
- B. Administer prescribed analgesics.
- C. Monitor temperature every 4 hours.
- D. Give antiemetics as needed for nausea.
Correct Answer: B
Rationale: Although all of the nursing actions may be used for patients with renal lithiasis, the patient's presentation indicates that management of pain is the highest priority action. If the patient has urinary obstruction, increasing oral fluids may increase the symptoms. There is no evidence of infection or nausea.