Nokea
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.
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The nurse is admitting an older-adult patient with benign prostatic hyperplasia. Which of the following actions should be included in the nursing plan of care?
- A. Limit fluid intake to no more than 1500 mL/day.
- B. Leave a light on in the bathroom during the night
- C. Pad the patient's bed to accommodate overflow incontinence.
- D. Ask the patient to use a urinal so that all urine can be measured.
Correct Answer: B
Rationale: The patient's age and diagnosis indicate a likelihood of nocturia, so leaving the light on in the bathroom is appropriate. Fluids should be encouraged because dehydration is more common in older patients. The information in the question does not indicate that measurement of the patient's output is necessary or that the patient has overflow incontinence.
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.
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.
The nurse is reviewing a patient's chart and notes that the patient has dysuria. To assess whether there is any improvement, which of the following questions should the nurse ask?
- A. Do you have any blood in your urine?
- B. Do you have to urinate very frequently?
- C. Do you have any pain when you urinate?
- D. Do you have to get up at night to urinate?
Correct Answer: C
Rationale: Dysuria is painful urination. The alternate responses are used to assess other urinary tract symptoms: hematuria, nocturia, and frequency.
A patient with a possible urinary tract infection (UTI) gives the nurse in the clinic a urine specimen that is an orange colour. Which of the following actions should the nurse take first?
- A. Notify the patient's health care provider.
- B. Ask the patient about use of any medications.
- C. Question the patient about any UTI risk factors.
- D. Teach about the correct procedure for midstream urine collection.
Correct Answer: B
Rationale: An orange colour in the urine is normal with some medications such as sulfasalazine. The colour would not be expected with urinary tract infection, is not a sign that poor technique was used in obtaining the specimen and does not need to be communicated to the health care provider until further assessment is done.