21.

Which of the following should the nurse include in the nursing care plan of the client who is diagnosed to have renal failure, whose BUN is 32 mg/dl, serum creatinine is 4 mg/dl, hematocrit is 38%. He is complaining of fatigue and edema. a) low protein diet and fluid restriction b) high protein diet and fluid restriction c) low protein diet and increase in fiber d) high protein diet and potassium restriction 22. The client in end-stage of renal failure had undergone kidney transplant. Which of the following assessment findings indicate kidney transplant rejection? a) increased urinary output, BUN = 15 mg/dL b) HCT = 50%, Hgb = 17 g/dl c) decreased urinary output, sudden weight gain d) decreased urinary output, sudden weight loss 23. Which of the following assessment findings indicates that pyridium is effective in a client with urinary tract infection? a) the client's urine culture yields negative result b) the client is able to void every 2 to 3 hours c) the client verbalizes that she is relieved from pain d) the client is able to void 30-60 ml/hour 24. Which of the following anti-hypertensive medications is contraindicated for clients with renal insufficiency? a) beta-adrenergic blockers b) calcium-channel blockers c) direct-acting vasodilators d) angiotensin-converting enzyme inhibitors 25. The client has been diagnosed to have glomerulonephritis. What should the nurse observe in the urine? a) blood b) pus c) white blood cells d) glucose

ANSWERS AND RATIONALE 21) A - the diet for a client with elevated BUN and serum creatine should be low protein, to reduce urea and nitrogenous waste products. For edema, fluid restriction should be implemented. 22) C

- kidney transplant rejection is manifested by failure of renal functions like decreased urinary output and water retention, as manifested by weight gain. 23) C - pyridium is a urinary analgesic. It will normally cause red-orange discoloration of the urine. 24) D - ACE inhibitors may cause hyperkalemia. It should be used with great caution if it is prescribed for a client with renal insufficiency. 25) A - glomerulonephritis causes gross hematuria. The urine appears dark, smoky, cola-colored, or red-brown.

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36. The client with acute renal failure has a serum potassium of 6.0 mEq/L. The nurse would plan which of the following as a priority action? a) check the sodium level b) place the client on a cardiac monitor c) encourage increased vegetables in the diet d) allow an extra 500 ml of fluid intake to dilute the electrolyte concentration 37. The client with chronic renal failure who is scheduled for hemodialysis this morning is due to receive a daily dose of enalapril (Vasotec). The nurse should plan to administer this medication: a) during dialysis b) just before dialysis c) the day after dialysis d) on return form dialysis

38. The client with chronic renal failure has an indwelling abdominal catheter for peritoneal dialysis. The client spills water on the catheter dressing while bathing. The nurse should immediately: a) change the dressing b) reinforce the dressing c) flush the peritoneal dialysis catheter d) scrub the catheter with povidine-iodine 39. The client hemodialyzed suddenly becomes short of breath and complains of chest pain. The client is tachycardic, pale and anxious. The nurse suspects air embolism. The priority action for the nurse is to: a) discontinue dialysis and notify the physician b) monitor vital signs every 15 minutes for the next hour c) continue dialysis at a slower rate after checking the lines for air d) bolus the client with 500 ml of normal saline to break up the air embolus 40. The nurse has completed client teaching with the hemodialysis client about self-monitoring between hemodialysis treatments. The nurse determines that the best understands the information if the client states to record daily the: a) amount of activity b) pulse and respiratory rate c) intake and output and weight d) blood urea nitrogen and creatinine levels

ANSWERS AND RATIONALE

36) B - The client with hyperkalemia is at risk of developing cardiac dysrhythmias and cardiac arrest. Because of this, the client should be placed on a cardiac monitor. Fluid intake is not increased because it contributes to fluid overload and would not affect the serum potassium level significantly. Vegetables are a natural source of potassium in the diet, and their use would not be increased. The nurse also may assess the sodium level because sodium is another electrolyte commonly measured with the potassium level. However, this is not a priority action of the nurse. 37) D - Antihypertensive medications such as enalapril are given to the client following hemodialysis. This prevents the client from becoming hypotensive during dialysis and also from having the medication removed from the bloodstream by dialysis. No rationale exists for waiting an entire day to resume the medication. This would lead to ineffective control of the blood pressure. 38) A - Clients with peritoneal dialysis catheters are at high risk for infection. A wet dressing is a conduit for bacteria to reach the catheter insertion site. The nurse ensures that the dressing is kept dry at all times. Reinforcing the dressing is not a safe practice to prevent infection in this circumstance. Flushing the catheter is not indicated. Scrubbing the catheter with povidone-iodine is done at the time of connection or disconnection of peritoneal dialysis. 39) A - If the client experiences air embolus during hemodialysis, the nurse should terminate dialysis immediately, notify the physician, and administer oxygen as needed. Options B, C, and D are incorrect. 40) C - The client on hemodialysis should monitor fluid status between hemodialysis treatments by recording intake and output and measuring weight daily. Ideally, the hemodialysis client should not gain more than 0.5 kg of weight/day.

1. The nurse is aware that the following findings would be further evidence of a urethral injury in a male client during rectal examination? a. A low-riding prostate b. The presence of a boggy mass c. Absent sphincter tone d. A positive Hemoccult 2. When a female client with an indwelling urinary (Foley) catheter insists on walking to the hospital lobby to visit with family members, nurse Rose teaches how to do this without compromising the catheter. Which client action indicates an accurate understanding of this information?

a. The client sets the drainage bag on the floor while sitting down. b. The client keeps the drainage bag below the bladder at all times. c. The client clamps the catheter drainage tubing while visiting with the family. d. The client loops the drainage tubing below its point of entry into the drainage bag. 3. A female client has just been diagnosed with condylomata acuminata (genital warts). What information is appropriate to tell this client? a. This condition puts her at a higher risk for cervical cancer; therefore, she should have a Papanicolaou (Pap) smear annually. b. The most common treatment is metronidazole (Flagyl), which should eradicate the problem within 7 to 10 days. c. The potential for transmission to her sexual partner will be eliminated if condoms are used every time they have sexual intercourse. d. The human papillomavirus (HPV), which causes condylomata acuminata, cant be transmitted during oral sex. 4. A male client with bladder cancer has had the bladder removed and an ileal conduit created for urine diversion. While changing this clients pouch, the nurse observes that the area around the stoma is red, weeping, and painful. What should nurse Katrina conclude? a. The skin wasnt lubricated before the pouch was applied. b. The pouch faceplate doesnt fit the stoma. c. A skin barrier was applied properly. d. Stoma dilation wasnt performed. 5. The nurse is aware that the following laboratory values supports a diagnosis of pyelonephritis? a. Myoglobinuria b. Ketonuria c. Pyuria d. Low white blood cell (WBC) count 6. A female client with chronic renal failure (CRF) is receiving a hemodialysis treatment. After hemodialysis, nurse Sarah knows that the client is most likely to experience: a. hematuria. b. weight loss. c. increased urine output. d. increased blood pressure. 7. Nurse Lea is assessing a male client diagnosed with gonorrhea. Which symptom most likely prompted the client to seek medical attention? a. Rashes on the palms of the hands and soles of the feet b. Cauliflower-like warts on the penis

c. Painful red papules on the shaft of the penis d. Foul-smelling discharge from the penis 8. Nurse Agnes is reviewing the report of a clients routine urinalysis. Which value should the nurse consider abnormal? a. Specific gravity of 1.03 b. Urine pH of 3.0 c. Absence of protein d. Absence of glucose 9. A male client is scheduled for a renal clearance test. Nurse Maureen should explain that this test is done to assess the kidneys ability to remove a substance from the plasma in: a. 1 minute. b. 30 minutes. c. 1 hour. d. 24 hours. 10. A male client in the short-procedure unit is recovering from renal angiography in which a femoral puncture site was used. When providing postprocedure care, the nurse should: a. keep the clients knee on the affected side bent for 6 hours. b. apply pressure to the puncture site for 30 minutes. c. check the clients pedal pulses frequently. d. remove the dressing on the puncture site after vital signs stabilize. 11. A female client is admitted for treatment of chronic renal failure (CRF). Nurse Juliet knows that this disorder increases the clients risk of: a. water and sodium retention secondary to a severe decrease in the glomerular filtration rate. b. a decreased serum phosphate level secondary to kidney failure. c. an increased serum calcium level secondary to kidney failure. d. metabolic alkalosis secondary to retention of hydrogen ions. 12. Because of difficulties with hemodialysis, peritoneal dialysis is initiated to treat a female clients uremia. Which finding signals a significant problem during this procedure? a. Potassium level of 3.5 mEq/L b. Hematocrit (HCT) of 35% c. Blood glucose level of 200 mg/dl d. White blood cell (WBC) count of 20,000/mm3 13. For a male client in the oliguric phase of acute renal failure (ARF), which nursing intervention is most important?

a. Encouraging coughing and deep breathing b. Promoting carbohydrate intake c. Limiting fluid intake d. Providing pain-relief measures 14. A female client requires hemodialysis. Which of the following drugs should be withheld before this procedure? a. Phosphate binders b. Insulin c. Antibiotics d. Cardiac glycosides 15. A client comes to the outpatient department complaining of vaginal discharge, dysuria, and genital irritation. Suspecting a sexually transmitted disease (STD), Dr. Smith orders diagnostic tests of the vaginal discharge. Which STD must be reported to the public health department? a. Chlamydia b. Gonorrhea c. Genital herpes d. Human papillomavirus infection 16. A male client with acute pyelonephritis receives a prescription for co-trimoxazole (Septra) P.O. twice daily for 10 days. Which finding best demonstrates that the client has followed the prescribed regimen? a. Urine output increases to 2,000 ml/day. b. Flank and abdominal discomfort decrease. c. Bacteria are absent on urine culture. d. The red blood cell (RBC) count is normal. 17. A 26-year-old female client seeks care for a possible infection. Her symptoms include burning on urination and frequent, urgent voiding of small amounts of urine. Shes placed on trimethoprim-sulfamethoxazole (Bactrim) to treat possible infection. Another medication is prescribed to decrease the pain and frequency. Which of the following is the most likely medication prescribed? a. nitrofurantoin (Macrodantin) b. ibuprofen (Motrin) c. acetaminophen with codeine d. phenazopyridine (Pyridium) 18. A triple-lumen indwelling urinary catheter is inserted for continuous bladder irrigation following a transurethral resection of the prostate. In addition to balloon inflation, the nurse is aware that the functions of the three lumens include:

a. Continuous inflow and outflow of irrigation solution. b. Intermittent inflow and continuous outflow of irrigation solution. c. Continuous inflow and intermittent outflow of irrigation solution. d. Intermittent flow of irrigation solution and prevention of hemorrhage. 19. Nurse Claudine is reviewing a clients fluid intake and output record. Fluid intake and urine output should relate in which way? a. Fluid intake should be double the urine output. b. Fluid intake should be approximately equal to the urine output. c. Fluid intake should be half the urine output. d. Fluid intake should be inversely proportional to the urine output. 20. After trying to conceive for a year, a couple consults an infertility specialist. When obtaining a history from the husband, nurse Jenny inquires about childhood infectious diseases. Which childhood infectious disease most significantly affects male fertility? a. Chickenpox b. Measles c. Mumps d. Scarlet fever 21. A male client comes to the emergency department complaining of sudden onset of sharp, severe pain in the lumbar region, which radiates around the side and toward the bladder. The client also reports nausea and vomiting and appears pale, diaphoretic, and anxious. The physician tentatively diagnoses renal calculi and orders flat-plate abdominal Xrays. Renal calculi can form anywhere in the urinary tract. What is their most common formation site? a. Kidney b. Ureter c. Bladder d. Urethra 22. A female client with acute renal failure is undergoing dialysis for the first time. The nurse in charge monitors the client closely for dialysis equilibrium syndrome, a complication that is most common during the first few dialysis sessions. Typically, dialysis equilibrium syndrome causes: a. confusion, headache, and seizures. b. acute bone pain and confusion. c. weakness, tingling, and cardiac arrhythmias. d. hypotension, tachycardia, and tachypnea. 23. Dr. Marquez prescribes norfloxacin (Noroxin), 400 mg P.O. twice daily, for a client with a urinary tract infection (UTI). The client asks the nurse how long to continue taking the drug. For an uncomplicated UTI, the usual duration of norfloxacin therapy is:

a. 3 to 5 days. b. 7 to 10 days. c. 12 to 14 days. d. 10 to 21 days. 24. Nurse Joy is providing postprocedure care for a client who underwent percutaneous lithotripsy. In this procedure, an ultrasonic probe inserted through a nephrostomy tube into the renal pelvis generates ultrahigh-frequency sound waves to shatter renal calculi. The nurse should instruct the client to: a. limit oral fluid intake for 1 to 2 weeks. b. report the presence of fine, sandlike particles through the nephrostomy tube. c. notify the physician about cloudy or foul-smelling urine. d. report bright pink urine within 24 hours after the procedure. 25. A client is frustrated and embarrassed by urinary incontinence. Which of the following measures should nurse Bea include in a bladder retraining program? a. Establishing a predetermined fluid intake pattern for the client b. Encouraging the client to increase the time between voidings c. Restricting fluid intake to reduce the need to void d. Assessing present elimination patterns

1. Answer B. When the urethra is ruptured, a hematoma or collection of blood separates the two sections of urethra. This may feel like a boggy mass on rectal examination. Because of the rupture and hematoma, the prostate becomes high riding. A palpable prostate gland usually indicates a nonurethral injury. Absent sphincter tone would refer to a spinal cord injury. The presence of blood would probably correlate with GI bleeding or a colon injury. 2. Answer B. To maintain effective drainage, the client should keep the drainage bag below the bladder; this allows the urine to flow by gravity from the bladder to the drainage bag. The client shouldnt lay the drainage bag on the floor because it could become grossly contaminated. The client shouldnt clamp the catheter drainage tubing because this impedes the flow of urine. To promote drainage, the client may loop the drainage tubing above not below its point of entry into the drainage bag. 3. Answer A. Women with condylomata acuminata are at risk for cancer of the cervix and vulva. Yearly Pap smears are very important for early detection. Because condylomata acuminata is a virus, there is no permanent cure. Because condylomata acuminata can occur on the vulva, a condom wont protect sexual partners. HPV can be transmitted to other parts of the body, such as the mouth, oropharynx, and larynx. 4. Answer B. If the pouch faceplate doesnt fit the stoma properly, the skin around the stoma will be exposed to continuous urine flow from the stoma, causing excoriation and red, weeping, and painful skin. A lubricant shouldnt be used because it would prevent the pouch from adhering to the skin. When properly applied, a skin barrier prevents skin excoriation. Stoma dilation isnt performed with an ileal conduit, although it may be done with a colostomy if ordered.

5. Answer C. Pyelonephritis is diagnosed by the presence of leukocytosis, hematuria, pyuria, and bacteriuria. The client exhibits fever, chills, and flank pain. Because there is often a septic picture, the WBC count is more likely to be high rather than low, as indicated in option D. Ketonuria indicates a diabetic state. 6. Answer B. Because CRF causes loss of renal function, the client with this disorder retains fluid. Hemodialysis removes this fluid, causing weight loss. Hematuria is unlikely to follow hemodialysis because the client with CRF usually forms little or no urine. Hemodialysis doesnt increase urine output because it doesnt correct the loss of kidney function, which severely decreases urine production in this disorder. By removing fluids, hemodialysis decreases rather than increases the blood pressure. 7. Answer D. Symptoms of gonorrhea in men include purulent, foul-smelling drainage from the penis and painful urination. Rashes on the palms of the hands and soles of the feet are symptoms of the secondary stage of syphilis. Cauliflower-like warts on the penis are a sign of human papillomavirus. Painful red papules on the shaft of the penis may be a sign of the first stage of genital herpes. 8. Answer B. Normal urine pH is 4.5 to 8; therefore, a urine pH of 3.0 is abnormal. Urine specific gravity normally ranges from 1.002 to 1.035, making this clients value normal. Normally, urine contains no protein, glucose, ketones, bilirubin, bacteria, casts, or crystals. Red blood cells should measure 0 to 3 per high-power field; white blood cells, 0 to 4 per high-power field. Urine should be clear, its color ranging from pale yellow to deep amber. 9. Answer A. The renal clearance test determines the kidneys ability to remove a substance from the plasma in 1 minute. It doesnt measure the kidneys ability to remove a substance over a longer period. 10. Answer C. After renal angiography involving a femoral puncture site, the nurse should check the clients pedal pulses frequently to detect reduced circulation to the feet caused by vascular injury. The nurse also should monitor vital signs for evidence of internal hemorrhage and should observe the puncture site frequently for fresh bleeding. The client should be kept on bed rest for several hours so the puncture site can seal completely. Keeping the clients knee bent is unnecessary. By the time the client returns to the shortprocedure unit, manual pressure over the puncture site is no longer needed because a pressure dressing is in place. The nurse shouldnt remove this dressing for several hours and only if instructed to do so. 11. Answer A. A client with CRF is at risk for fluid imbalance dehydration if the kidneys fail to concentrate urine, or fluid retention if the kidneys fail to produce urine. Electrolyte imbalances associated with this disorder result from the kidneys inability to excrete phosphorus; such imbalances may lead to hyperphosphatemia with reciprocal hypocalcemia. CRF may cause metabolic acidosis, not metabolic alkalosis, secondary to inability of the kidneys to excrete hydrogen ions. 12. Answer D. An increased WBC count indicates infection, probably resulting from peritonitis, which may have been caused by insertion of the peritoneal catheter into the peritoneal cavity. Peritonitis can cause the peritoneal membrane to lose its ability to filter solutes; therefore, peritoneal dialysis would no longer be a treatment option for this client. Hyperglycemia occurs during peritoneal dialysis because of the high glucose content of the dialysate; its readily treatable with sliding-scale insulin. A potassium level of 3.5 mEq/L can be treated by adding potassium to the dialysate solution. An HCT of 35% is lower than

normal. However, in this client, the value isnt abnormally low because of the daily blood samplings. A lower HCT is common in clients with chronic renal failure because of the lack of erythropoietin. 13. Answer C. During the oliguric phase of ARF, urine output decreases markedly, possibly leading to fluid overload. Limiting oral and I.V. fluid intake can prevent fluid overload and its complications, such as heart failure and pulmonary edema. Encouraging coughing and deep breathing is important for clients with various respiratory disorders. Promoting carbohydrate intake may be helpful in ARF but doesnt take precedence over fluid limitation. Controlling pain isnt important because ARF rarely causes pain. 14. Answer D. Cardiac glycosides such as digoxin should be withheld before hemodialysis. Hypokalemia is one of the electrolyte shifts that occur during dialysis, and a hypokalemic client is at risk for arrhythmias secondary to digitalis toxicity. Phosphate binders and insulin can be administered because they arent removed from the blood by dialysis. Some antibiotics are removed by dialysis and should be administered after the procedure to ensure their therapeutic effects. The nurse should check a formulary to determine whether a particular antibiotic should be administered before or after dialysis. 15. Answer B. Gonorrhea must be reported to the public health department. Chlamydia, genital herpes, and human papillomavirus infection arent reportable diseases. 16. Answer C. Co-trimoxazole is a sulfonamide antibiotic used to treat urinary tract infections. Therefore, absence of bacteria on urine culture indicates that the drug has achieved its desired effect. Although flank pain may decrease as the infection resolves, this isnt a reliable indicator of the drugs effectiveness. Co-trimoxazole doesnt affect urine output or the RBC count. 17. Answer D. Phenazopyridine may be prescribed in conjunction with an antibiotic for painful bladder infections to promote comfort. Because of its local anesthetic action on the urinary mucosa, phenazopyridine specifically relieves bladder pain. Nitrofurantoin is a urinary antiseptic with no analgesic properties. While ibuprofen and acetaminophen with codeine are analgesics, they dont exert a direct effect on the urinary mucosa. 18. Answer A. When preparing for continuous bladder irrigation, a triple-lumen indwelling urinary catheter is inserted. The three lumens provide for balloon inflation and continuous inflow and outflow of irrigation solution. 19. Answer B. Normally, fluid intake is approximately equal to the urine output. Any other relationship signals an abnormality. For example, fluid intake that is double the urine output indicates fluid retention; fluid intake that is half the urine output indicates dehydration. Normally, fluid intake isnt inversely proportional to the urine output. 20. Answer C. Mumps is the most significant childhood infectious disease affecting male fertility. Chickenpox, measles, and scarlet fever dont affect male fertility. 21. Answer A. The most common site of renal calculi formation is the kidney. Calculi may travel down the urinary tract with or without causing damage and may lodge anywhere along the tract or may stay within the kidney. The ureter, bladder, and urethra are less common sites of renal calculi formation.

22. Answer A. Dialysis equilibrium syndrome causes confusion, a decreasing level of consciousness, headache, and seizures. These findings, which may last several days, probably result from a relative excess of interstitial or intracellular solutes caused by rapid solute removal from the blood. The resultant organ swelling interferes with normal physiologic functions. To prevent this syndrome, many dialysis centers keep first-time sessions short and use a reduced blood flow rate. Acute bone pain and confusion are associated with aluminum intoxication, another potential complication of dialysis. Weakness, tingling, and cardiac arrhythmias suggest hyperkalemia, which is associated with renal failure. Hypotension, tachycardia, and tachypnea signal hemorrhage, another dialysis complication. 23. Answer B. For an uncomplicated UTI, norfloxacin therapy usually lasts 7 to 10 days. Taking the drug for less than 7 days wouldnt eradicate such an infection. Taking it for more than 10 days isnt necessary. Only a client with a complicated UTI must take norfloxacin for 10 to 21 days. 24. Answer C. The client should report the presence of foul-smelling or cloudy urine. Unless contraindicated, the client should be instructed to drink large quantities of fluid each day to flush the kidneys. Sandlike debris is normal due to residual stone products. Hematuria is common after lithotripsy. 25. Answer D. The guidelines for initiating bladder retraining include assessing the clients intake patterns, voiding patterns, and reasons for each accidental voiding. Lowering the clients fluid intake wont reduce or prevent incontinence. The client should actually be encouraged to drink 1.5 to 2 L of water per day. A voiding schedule should be established after assessment.