Nokea
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.
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Which of the following findings by the nurse for a patient admitted with glomerulonephritis indicates that treatment has been effective?
- A. The patient denies pain with voiding.
- B. The urine dipstick is negative for nitrites.
- C. Peripheral and periorbital edema is resolved.
- D. The antistreptolysin-O (ASO) titre is decreased.
Correct Answer: C
Rationale: Since edema is a common clinical manifestation of glomerulonephritis, resolution of the edema indicates that the prescribed therapies have been effective. Antibodies to streptococcus will persist after a streptococcal infection. Nitrites will be negative and the patient will not experience dysuria since the patient does not have a urinary tract infection.
The home health nurse is teaching a patient with a neurogenic bladder how to use intermittent catheterization for bladder emptying. Which of the following patient statements indicates that the teaching has been effective?
- A. I will use a sterile catheter and gloves for each time I self-catheterize.
- B. I will clean the catheter carefully before and after each catheterization.
- C. I will need to buy seven new catheters weekly and use a new one every day.
- D. I will need to take prophylactic antibiotics to prevent any urinary tract infections.
Correct Answer: B
Rationale: Patients who are at home can use a clean technique for intermittent self-catheterization and change the catheter every 7 days. There is no need to use a new catheter every day, to use sterile catheters, or to take prophylactic antibiotics.
The nurse is providing patient teaching to a patient with cystitis regarding prevention of future urinary tract infections (UTIs). Which of the following patient statements indicate that teaching has been effective?
- A. I can use vaginal sprays to reduce bacteria.
- B. I will drink a litre of water or other fluids every day.
- C. I will wash with soap and water before sexual intercourse.
- D. I will empty my bladder every 2-4 hours during the day.
Correct Answer: D
Rationale: Voiding every 2-4 hours is recommended to prevent UTIs. Use of vaginal sprays is discouraged. The bladder should be emptied before and after intercourse, but cleaning with soap and water is not necessary. A litre of fluids is insufficient to provide adequate urine output to decrease risk for UTI.
The nurse is caring for a patient who had a nephrectomy after having massive trauma to the kidney. Which of the following assessment findings obtained postoperatively is most important to communicate to the surgeon?
- A. Blood pressure is 102/58.
- B. Incisional pain level is 8/10.
- C. Urine output is 20 ml/hour for 2 hours.
- D. Crackles are heard at both lung bases.
Correct Answer: C
Rationale: Because the urine output should be at least 0.5 ml/kg/hour, a 20 ml output for 2 hours indicates that the patient may have decreased renal perfusion because of bleeding, inadequate fluid intake, or obstruction at the suture site. The blood pressure requires ongoing monitoring but does not indicate inadequate perfusion at this time. The patient should cough and deep breathe, but the crackles do not indicate a need for an immediate change in therapy. The incisional pain should be addressed, but this is not as potentially life-threatening as decreased renal perfusion.
The nurse is preparing a patient with bladder cancer for intravesical chemotherapy. Which of the following information should the nurse teach the patient about in preparation for the treatment?
- A. Premedicating to prevent nausea
- B. Where to obtain wigs and scarves
- C. The importance of oral care during treatment
- D. The need to empty the bladder before treatment
Correct Answer: D
Rationale: Intravesical chemotherapy is the instillation of the agent directly into the bladder, therefore the patient needs to have an empty bladder before the instillation of the chemotherapy. Systemic adverse effects are not experienced with intravesical chemotherapy.