PRACTICE URINARY HESI TEST 158 Questions with Verified Answers
The nurse is caring for a client with a diagnosis of acute kidney failure associated
... [Show More] with drug toxicity. When the client complains of thirst, the nurse should offer:
Ice chips
Warm milk
Hard candy
Carbonated soda - CORRECT ANSWER Hard candy
Sucking on candy will relieve thirst and provide calories without supplying extra fluid. Ice chips add to the restricted fluid intake. Milk contains both fluids and proteins, which should be restricted with acute kidney failure. Carbonated beverages may be high in sodium and provide additional fluid; both should be restricted.
Test-Taking Tip: Identify option components as correct or incorrect. This may help you identify a wrong answer. Example: If you are being asked to identify a diet that is specific to a certain condition, your knowledge about that condition would help you choose the correct response (e.g., cholecystectomy = low fat, high protein, low-calorie diet ).
1. A nurse assesses a newly admitted client with renal colic to determine the signs and symptoms that are present. The nurse assesses the client for which primary subjective symptom?
1 Uremia
2 Nausea
3 Voiding at night
4 Flank discomfort - CORRECT ANSWER 4
A subjective symptom must be experienced and described by the client; flank pain, pain on the side of the body between the ribs and the ileum, accompanies renal colic. Uremia and voiding at night are objective signs that can be verified by observation or measurement. Although nausea is a subjective symptom and can occur with the severe pain associated with renal colic, it is not as significant as flank pain
1. Which statement regarding treatment with interferon indicates that the client understands the nurse's teaching?
1 "I will drink two to three quarts of fluid a day."
2 "Any reconstituted solution must be discarded in one week."
3 "I can continue driving my car as long as I have the stamina."
4 "While taking this medicine I should be able to continue my usual activity." - CORRECT ANSWER 1
Adequate fluid intake helps to flush the kidneys and prevent nephrotoxicity, especially during the early phase of treatment. Reconstituted solution may be stored in the refrigerator for one month. Confusion, dizziness, and hallucinations are side effects of this drug; the client should avoid hazardous tasks, such as driving or using machinery. Activity may have to be altered because fatigue and other flu-like symptoms are common with this drug
A nurse is caring for a client with an indwelling urinary catheter. What is the most important action for the nurse to implement when irrigating the bladder?
1 Use sterile equipment.
2 Instill the fluid under high pressure.
3 Warm the solution to body temperature.
4 Aspirate immediately to ensure return flow - CORRECT ANSWER 1
The bladder is a sterile body cavity; when introducing a solution/catheter, surgical asepsis is required. Excessive pressure can traumatize the lining of the urinary tract. The solution generally is administered at room temperature. Aspirating immediately to ensure return flow is done if the fluid does not return by gravity; the negative pressure exerted during aspiration may cause trauma.
An older client who is living in a nursing home is admitted to the hospital to be treated with intravenous antibiotics for sepsis resulting from a urinary tract infection. The client becomes agitated and attempts to pull out the IV. The health care provider prescribes a stat dose of haloperidol (Haldol) 0.5 mg IM. The haloperidol is available in a vial that states there are 2 mg/mL. How much solution should the nurse administer? Include a leading zero if applicable. Record your answer using two decimal places. __________ mL - CORRECT ANSWER 0.25 mL
Solve the problem by using ratio and proportion. Desire 0.5 mg x mL------------- = ----Have 2 mg 1 mL2x = 0.5x = 0.5 ÷ 2x = 0.25 mL
Test-Taking Tip: When taking the NCLEX exam, an on-screen calculator will be available for you to determine your response, which you will then type in the provided space.
A client who is diagnosed with sexual dysfunction makes a comment to the nurse, "Well, I guess my sex life is over." What is the most appropriate response by the nurse?
1 "I'm sorry to hear that."
2 "Oh, you have a lot of good years left."
3 "You are concerned about your sex life?"
4 "Have you asked your health care provider about that?" - CORRECT ANSWER 3
The response "You are concerned about your sex life?" explores the meaning of the statement and allows further expression of concern. The response "I'm sorry to hear that" does not allow an explanation of feelings and cuts off communication. The response "Oh, you have a lot of good years left" lacks both empathy and understanding; it also cuts off communication. The response "Have you asked your health care provider about that?" shirks responsibility; the client may be embarrassed to ask the health care provider and needs the nurse to act as facilitator.
A routine urinalysis is prescribed for a client. What should the nurse do if the specimen cannot be sent immediately to the laboratory?
1 Take no special action.
2 Refrigerate the specimen.
3 Store it in the dirty utility room and send it later.
4 Discard the specimen and collect another specimen later. - CORRECT ANSWER 2
Refrigeration retards the growth of bacteria and may preserve the specimen for several hours. Growth of bacteria will alter the pH and the glucose and protein levels in the urine; it must be refrigerated to retard growth. Discarding the specimen and collecting another specimen later represents an unnecessary waste of time, effort, and money.
Test-Taking Tip: Being emotionally prepared for an examination is key to your success. Proper use of this text over an extended period of time ensures your understanding of the mechanics of the examination and increases your confidence about your nursing knowledge. Your lifelong dream of becoming a nurse is now within your reach! You are excited, yet anxious. This feeling is normal. A little anxiety can be good because it increases awareness of reality; but excessive anxiety has the opposite effect, acting as a barrier and keeping you from reaching your goal. Your attitude about yourself and your goals will help keep you focused, adding to your strength and inner conviction to achieve success.
A nurse administers trimethoprim-sulfamethoxazole (Bactrim) to a client diagnosed with a urinary tract infection. What should the nurse monitor to determine the therapeutic effectiveness of the drug?
1 Breath sounds
2 Hemoglobin level
3 Consistency of stool
4 White blood cell (WBC) count - CORRECT ANSWER 4
Trimethoprim-sulfamethoxazole blocks two consecutive steps in the bacterial synthesis of essential nucleic acids and protein; resolution of infection is reflected by a WBC in the expected range. This drug may be used to treat various types of infections; therapeutic responses will depend on the location of the infection, which is not specified. This drug may cause hemolytic anemia, which alters the hemoglobin level, but this is a side effect. This drug may be used to treat various types of infections; therapeutic responses will depend on the location of the infection, which is not specified.
A nurse is caring for a client who had a kidney transplant. What sign indicates that the client may be rejecting the transplanted kidney?
1 Fever
2 Hematuria
3 Moon face
4Yellow sclera - CORRECT ANSWER 1
Fever is a characteristic of the systemic inflammatory response to the antigen (transplanted kidney). Hematuria is not indicative of rejection; however, its occurrence necessitates further investigation. A moon face (moon facies) is an effect of steroid therapy and does not indicate rejection. Jaundice is unrelated to rejection of a transplanted kidney.
The nurse reviews the medical records of four male clients and concludes that the client that is at highest risk of developing prostate cancer is the:
1 Black 55-year-old
2 White 45-year-old
3 Asian 55-year-old
4 Hispanic 45-year-old - CORRECT ANSWER 1
Cancer of the prostate is rare before age 50 but increases with each decade; black men develop cancer of the prostate twice as often and at an earlier age than white men. White men develop prostatic cancer half as often as black men, but more commonly than Asian or Hispanic men. Asian and Hispanic men have a lower incidence of prostatic cancer and a lower mortality rate than white and black men.
A male client has discharge from his penis. Gonorrhea is suspected. To obtain a specimen for a culture, the nurse should:
1 Instruct the client to provide a semen specimen
2 Swab the discharge when it appears on the prepuce
3Teach the client how to obtain a clean catch specimen of urine
4 Swab the drainage directly from the urethra to obtain a specimen - CORRECT ANSWER 4
Swabbing the drainage directly from the urethra obtains a specimen uncontaminated by environmental organisms. Instructing the client to provide a semen specimen is not as accurate as obtaining the purulent discharge from the site of origin. Swabbing the discharge when it appears on the prepuce will contaminate the specimen with organisms external to the body. Teaching the client how to obtain a clean catch specimen of urine will dilute and possibly contaminate the specimen.
STUDY TIP: Do not change your pattern of study. It obviously has contributed to your being here, so it worked. If you have studied alone, continue to study alone. If you have studied in a group, form a study group.
Nitrofurantoin (Macrobid) 0.1 gm is prescribed for a client with a urinary tract infection. Each tablet contains 50 mg. How many tablets should the nurse administer? Record your answer using a whole number. __________ tablets - CORRECT ANSWER 2 tablets
First convert 0.1 g to its equivalent in mg by multiplying by 1000 (move the decimal 3 places to the right). Use the "Desire over Have" formula of ratio and proportion to solve the problem.Desire 100 mg x tablets---------------- = ---------Have 50 mg 1 tablet50x = 100x = 100 ÷ 50x = 2 tablets
A female client has a history of frequent urinary tract infections (UTIs). To decrease the incidence of the infections, the nurse instructs the client to increase fluid intake and:
1 Empty the bladder every three hours
2 Take warm bubble baths
3 Wipe from back to front
4 Take a prophylactic antibiotic after sexual intercourse - CORRECT ANSWER 1
Emptying the bladder every three hours helps prevent stasis of urine; urinary stasis supports bacterial growth. Tub baths with soapy bubbles are thought to increase, not decrease, the risk of UTIs because soap is irritating to mucous membranes. It is not necessary to wash the perineal area from the urethra toward the rectum. The concern about wiping from back to front is allowing fecal material to enter the perineal area and potentially cause irritation. The nurse should, however, take into consideration the different schools of thought about wiping from the urethral area to the rectal area. Taking a prophylactic antibiotic after sexual intercourse is an inappropriate use of antibiotics that may support the development of resistant strains of bacteria; antibiotics should be used judiciously and be prescribed by a licensed health care provider.
A nurse is planning to administer a prescribed intravenous solution that contains potassium chloride. What assessment should be brought to the health care provider's attention before administration of the intravenous (IV) line?
1 Uncharacteristic irritability
2 Poor tissue turgor with tenting
3 Urinary output of 200 mL during the previous 8 hours
4 Oral fluid intake of 300 mL during the previous 12 hours - CORRECT ANSWER 3
Decreased urinary output will result in the retention of potassium, causing hyperkalemia. Reporting uncharacteristic irritability is unnecessary; this is a sign of dehydration, which can be corrected with appropriate hydration. Reporting poor tissue turgor with tenting is unnecessary; this may indicate dehydration, which is probably the rationale for the fluid prescribed. Reporting an oral fluid intake of 300 mL during the previous 12 hours is unnecessary; this can precipitate dehydration or can compound an existing dehydration, which can be treated with appropriate hydration.
The nurse recalls that what scientific principle is basic to caring for a client with an indwelling urinary catheter?
1 Inertia
2 Gravity
3 Osmosis
4Diffusion - CORRECT ANSWER 2
An indwelling urinary catheter always is positioned so that the level of the bladder is higher than the level of the drainage container; gravity promotes urine flow. Inertia refers to a property of matter. Osmosis refers to the movement of water across a semipermeable membrane; it is not responsible for the flow of urine through a catheter. Diffusion refers to the passage of molecules from an area of higher concentration to one of lower concentration.
A nurse is counseling a woman who had recurrent urinary tract infections. What factor should the nurse explain is the reason why women are at a greater risk than men for contracting a urinary tract infection?
1 Altered urinary pH
2 Hormonal secretions
3 Juxtaposition of the bladder
4 Proximity of the urethra to the anus - CORRECT ANSWER 4
Because the female's urethra is closer to the anus than the male's, it is at greater risk for becoming contaminated. Urinary pH is within the same range in both males and females. Hormonal secretions have no effect on the development of bladder infections. The position of the bladder is the same in males and females.
A nurse is providing postoperative care to a client who had a kidney transplant. What assessment is the best indicator of the functioning of the newly transplanted kidney?
1 Renal scan
2 Serum creatinine
3 White blood cell (WBC) count
4 Intake and output balance daily - CORRECT ANSWER 2
Serum creatinine, a test of renal function, measures the kidneys' ability to excrete metabolic wastes; creatinine, a nitrogenous product of protein breakdown, is increased with kidney insufficiency. A renal scan does not provide information about the filtering ability of the new kidney. A WBC count does not reflect functioning of the new kidney. Although intake and output should be monitored, this does not provide information about the kidneys' ability to excrete metabolic wastes.
A client with a urinary retention catheter reports discomfort in the bladder and urethra. What should the nurse do first?
1 Milk the tubing gently.
2 Notify the health care provider.
3 Check the patency of the catheter.
4 Irrigate the catheter with prescribed solutions. - CORRECT ANSWER 3
Checking the patency of the catheter ensures drainage and prevents bladder distention and other complications. Patency of the catheter should be established before any other intervention. Milking the tubing gently is premature; this may be necessary if the catheter is clogged and usually is required when the drainage is viscous rather than liquid. Assessment is necessary before consultation with the health care provider. Irrigation is avoided if possible because of the associated risk for infection.
A client is receiving furosemide (Lasix) to relieve edema. The nurse should monitor the client for which response to the medication?
1 Retention of sodium ions
2 Negative nitrogen balance
3 Excessive loss of potassium ions
4 Increase in the urine specific gravity - CORRECT ANSWER 3
Furosemide is a potent diuretic used to provide rapid diuresis; it acts in the loop of Henle and causes depletion of electrolytes, such as potassium and sodium. Furosemide inhibits the reabsorption, not retention, of sodium. Furosemide does not affect protein metabolism. With edema, the specific gravity of the fluid more likely will be low.
Test-Taking Tip: Pace yourself when taking practice quizzes. Because most nursing exams have specified time limits, you should pace yourself during the practice testing period accordingly. It is helpful to estimate the time that can be spent on each item and still complete the examination in the allotted time. You can obtain this figure by dividing the testing time by the number of items on the test. For example, a 1-hour (60-minute) testing period with 50 items averages 1.2 minutes per question. The NCLEX exam is not a timed test. Both the number of questions and the time to complete the test varies according to each candidate's performance. However, if the test taker uses the maximum of 5 hours to answer the maximum of 265 questions, each question equals 1.3 minutes.
A client who is recovering from deep partial-thickness burns develops chills, fever, flank pain, and malaise. The health care provider makes a tentative diagnosis of urinary tract infection. Which diagnostic tests should the nurse expect the health care provider to prescribe to confirm this diagnosis?
1 Urinalysis and urine culture and sensitivity
2 Cystoscopy and bilirubin level
3 Creatinine clearance and albumin/globulin (A/G) ratio
4 Specific gravity and pH of the urine - CORRECT ANSWER 1.
The client's adaptations may indicate a urinary tract infection; a culture of the urine will identify the microorganism. A cystoscopy is too invasive as a screening procedure; altered bilirubin results indicate liver or biliary problems, not urinary signs and symptoms. Creatinine clearance reflects renal function; A/G ratio reflects liver function. Although an increased urine specific gravity may indicate red blood cells (RBCs), white blood cells (WBCs), or casts in the urine, which are associated with urinary tract infection, it will not identify the causative organism.
A client will be taking nitrofurantoin (Macrobid) 50 mg orally every evening at home to manage recurrent urinary tract infections. What instructions should the nurse give to the client?
1 Increase the intake of fluids.
2 Strain the urine for crystals and stones.
3 Stop the drug if urinary output increases.
4 Maintain the exact time schedule for taking the drug - CORRECT ANSWER 1
To prevent crystal formation, the client should have sufficient intake to produce 1000 to 1500 mL of urine daily while taking this drug. Straining urine is not indicated when the client is taking a urinary antiinfective. Urinary decrease is of concern because it may indicate renal failure. If fluids are encouraged, the client's output should increase. The drug need not be taken at a strict time daily.
Which action should be included in the plan of care for a client who has had pelvic surgery
1 Encouraging the client to ambulate in the hallway.
2 Elevating the client's legs by raising the bed's knee support.
3 Assisting the client to dangle the legs over the side of the bed.
4 Maintaining the client on bed rest until the bandages are removed. - CORRECT ANSWER 1
Muscle contractions during ambulation improves venous return, preventing venous stasis and thrombus formation. Elevating the client's legs by raising the bed's knee support places pressure on popliteal spaces, limiting venous return and increasing the risk for thrombus formation. Assisting the client to dangle the legs over the side of the bed places pressure on popliteal spaces, limiting venous return and increasing the risk for thrombus formation. Bed rest is associated with venous stasis, which increases the risk for thrombus formation.
A nurse teaches a client who is scheduled for a kidney transplant about the need for immunosuppressive medications. The nurse determines that the client understands the teaching when the client states, "I must take these medications:
1 For the rest of my life."
2 Until the surgery is over."
3 Until the anastomosis heals."
4 During the intraoperative period." - CORRECT ANSWER 1
These drugs must be taken continuously to prevent rejection of the transplanted organ. The danger of rejection always exists. The client must take the medications longer than after the surgery or until the anastomosis heals or during the intraoperative period. Test-Taking Tip: Be alert for grammatical inconsistencies. If the response is intended to complete the stem (an incomplete sentence) but makes no grammatical sense to you, it might be a distractor rather than the correct response. Question writers typically try to eliminate these inconsistencies.
A lithotripsy to break up renal calculi is unsuccessful, and a nephrolithotomy is performed. Which postoperative clinical indicator should the nurse report to the health care provider?
1 Passage of pink-tinged urine
2 Pink drainage on the dressing
3 Intake of 1750 mL in 24 hours
4 Urine output of 20 to 30 mL/hr - CORRECT ANSWER 4
Output should be at least 30 mL/hr or more; a decreased output may indicate obstruction or impaired kidney function. Blood, tinting the urine pink, is expected. Drainage may be pink; bright red drainage should be reported. The intake of 1750 mL in 24 hours is adequate; however, a higher intake usually is preferred (e.g., 2000 to 3000 mL).
A nurse is caring for a client who just had surgery to repair an inguinal hernia. To limit a common complication associated with this surgery, the nurse should:
1 Apply an abdominal binder
2 Place a support under the scrotum
3 Teach the client to cough several times an hour
4 Encourage the client to eat a high carbohydrate diet - CORRECT ANSWER 2
After inguinal hernia repair, the scrotum commonly becomes edematous and painful; drainage is facilitated by elevating the scrotum on rolled linen or using a scrotal support. An abdominal binder will not support the operative site; the incision is too low. Coughing increases intraabdominal pressure and should be avoided because it strains the operative site. Obesity is a factor in the development of hernias; high carbohydrate diets should be discouraged.
A client with chronic renal failure has been on hemodialysis for two years. The client communicates with the nurse in the dialysis unit in an angry, critical manner and is frequently noncompliant with medications and diet. The nurse can best intervene by first considering that the client's behavior is most likely:
1 An attempt to punish the nursing staff
2 A constructive method of accepting reality
3 A defense against underlying depression and fear
4 An effort to maintain life and to live it as fully as possible - CORRECT ANSWER 3
Both hostility and noncompliance are forms of anger that are associated with grieving. The client's behavior is not a conscious attempt to hurt others but a way to relieve and reduce anxiety within the self. The client's behavior is a self-destructive method of coping, which can result in death. The client's behavior is an effort to maintain control over a situation that is really controlling the client; it is an unconscious method of coping, and noncompliance may be a form of denial. Test-Taking Tip: Once you have decided on an answer, look at the stem again. Does your choice answer the question that was asked? If the question stem asks "why," be sure the response you have chosen is a reason. If the question stem is singular, then be sure the option is singular, and the same for plural stems and plural responses. Many times, checking to make sure that the choice makes sense in relation to the stem will reveal the correct answer.
A client is diagnosed as having invasive cancer of the bladder, and radiation therapy is scheduled. What should the nurse expect the client to demonstrate that indicates success of radiation therapy?
1 Decrease in urine output
2 Increase in physical strength
3 Shrinkage of the tumor on scanning
4 Increase in the quantity of white blood cells (WBCs) - CORRECT ANSWER 3
Radiation interferes with cell multiplication, which should control the growth and metastasis of cancerous tumors. Radiation affects healthy as well as abnormal cells; urinary frequency and diarrhea can result. Malaise, not an increase in physical strength, is an effect of radiation therapy. Bone marrow sites may be affected by radiation, resulting in a reduction of WBCs.
A pathology report states that a client's urinary calculus is composed of uric acid. Which should the nurse instruct the client to avoid?
1 Milk
2Liver
3Cheese
4 Vegetables - CORRECT ANSWER 2
Uric acid stones are controlled by a low-purine diet. Foods high in purine, such as organ meats and extracts, should be avoided. Milk should be avoided with calcium, not uric acid, stones. Cheese should be avoided with cystine, not uric acid, stones. Vegetables do not have to be avoided; however, legumes should be kept to a minimum.
A nurse is caring for a client with a diagnosis of renal calculi secondary to hyperparathyroidism. Which type of diet should the nurse explore with the client when providing discharge information?
1 Low purine
2 Low calcium
3 High phosphorus
4 High alkaline ash - CORRECT ANSWER 2
Calcium and phosphorus are components of these stones; foods high in calcium and phosphorus should be avoided. Low purine and high alkaline ash diets are indicated for clients with gout. Foods high in phosphorus must be avoided.
Test-Taking Tip: Be aware that information from previously asked questions may help you respond to other examination questions.
A nurse is caring for a client who had a kidney transplant. What sign indicates that the client may be rejecting the transplanted kidney?
1 Fever
2 Hematuria
3 Moon face
4 Yellow sclera - CORRECT ANSWER 1
Fever is a characteristic of the systemic inflammatory response to the antigen (transplanted kidney). Hematuria is not indicative of rejection; however, its occurrence necessitates further investigation. A moon face (moon facies) is an effect of steroid therapy and does not indicate rejection. Jaundice is unrelated to rejection of a transplanted kidney.
The nurse reviews the medical records of four male clients and concludes that the client that is at highest risk of developing prostate cancer is the:
1.Black 55-year-old
2 White 45-year-old
3 Asian 55-year-old
4Hispanic 45-year-old - CORRECT ANSWER 1
Cancer of the prostate is rare before age 50 but increases with each decade; black men develop cancer of the prostate twice as often and at an earlier age than white men. White men develop prostatic cancer half as often as black men, but more commonly than Asian or Hispanic men. Asian and Hispanic men have a lower incidence of prostatic cancer and a lower mortality rate than white and black men.
A client just had a suprapubic prostatectomy. Which action should the nurse implement to prevent a secondary bladder infection?
1 Observe for signs of uremia
2 Attach the catheter to suction
3 Clamp off the connecting tube
4 Change the dressings frequently - CORRECT ANSWER 4
After a suprapubic prostatectomy, leakage of urine generally is identified around the suprapubic tube; this creates an environment in which bacteria can flourish if the dressing is not changed frequently. Uremia is caused by inadequate kidney function; it is not directly related to bladder infection. Negative pressure on the bladder may traumatize the delicate tissue; urine should flow because of gravity. Clamping off the tube causes urinary stasis, which increases the risk for infection.Test-Taking Tip: Stay away from other nervous students before the test. Stop reviewing at least 30 minutes before the test. Take a walk, go to the library and read a magazine, listen to music, or do something else that is relaxing. Go to the test room a few minutes before class time so that you are not rushed in settling down in your seat. Tune out what others are saying. Crowd tension is contagious, so stay away from it.
An older adult client states, "I walk 2 miles a day for exercise, but now that the weather is hot, I am worried about becoming dehydrated." What should the nurse teach the client?
1 Drink fruit juices if you start to feel dehydrated.
2 Thirst is a good guide to use to determine fluid intake.
3 Fluids should be increased if the urine is getting darker.
4 Water should be consumed when the skin becomes dry - CORRECT ANSWER 3
In hot weather, dark-colored urine indicates dehydration. The amount of fluid to be excreted is less, and the body is attempting to conserve fluid. Fruit juices should be avoided during rehydration because of their high sugar content. By the time people become thirsty, they already are dehydrated, especially older adults. Dry skin in older adults may be related to aging rather than to dehydration. Water intake should be adequate (in hot weather, dark-colored urine indicates dehydration. The amount of fluid to be excreted is less, and the body is attempting to conserve fluid. Approximately 2000 mL daily is needed) and spaced throughout the day.
A postmenopausal woman who has cancer of the breast decides to have a lumpectomy followed by chemotherapy. After receiving chemotherapy for several weeks, she says to a nurse at the clinic, "I don't feel well." The nurse reviews the medical record. Based on this information, what does the nurse conclude is the client's priority need?
1 Promoting rest
2 Preventing infection
3 Avoiding bodily harm
4 Maintaining fluid balance - CORRECT ANSWER 2
The prevention of infection is the priority because an infection can be life-threatening for a client who is immunocompromised. Chemotherapeutic medications depress the bone marrow, causing leukopenia. This client's white blood cell count is below the expected range of 4500 to 11,000/mm3 for an older female adult. Although the elevation in the client's temperature, pulse, and respirations may be related to the direct effects of the chemotherapeutic agents, they also may reflect that the client is resisting a microbiological stress. Although a balance between rest and activity is important, it is not the priority . While chemotherapeutic medications depress the bone marrow and cause anemia, this client's red blood cell count is within the expected range of 4.0 to 5.0 million/mm 3 for an older female adult. The client's hemoglobin level is within the expected range of 11.5 to 16.0 g/dL. Even though preventing injury is important, it is not the priority . Although chemotherapeutic medications depress the bone marrow, causing thrombocytopenia, this client's platelet count is within the expected range of 150,000 to 400,000/mm 3 for an adult. While maintaining fluid balance is important, it is not the priority . The client's hematocrit is within the expected range of 38% to 41% for an older female adult, indicating that the client is not dehydrated. The client's blood pressure is not decreased, which occurs with dehydration. Although chemotherapeutic medications may cause nausea, vomiting, and diarrhea, the client did not indicate that these occurred.
A client who is dehydrated is to receive an intravenous (IV) solution of normal saline to be infused at 175 mL/hr. The drop factor of the IV set is 15 gtts/mL. At what drop rate should the nurse adjust the flow to provide the prescribed solution? Record your answer using a whole number. __________ gtts/min - CORRECT ANSWER 44
44 gtts/min is a correct calculation. Multiply the amount of fluid to be infused (175 mL) by the drop factor (15) and divide this result by the amount of time in minutes (1 hr x 60 min).
A client experiences difficulty in voiding after an indwelling urinary catheter is removed. The nurse determines that this difficulty most likely is related to:
1 Fluid imbalance
2 Sedentary lifestyle
3 Interruption in previous voiding habits
4 Nervous tension following the procedure - CORRECT ANSWER 3
An indwelling catheter dilates the urinary sphincters, keeps the bladder empty, and short-circuits the reflex mechanism based on bladder distention. When the catheter is removed, the body must adapt to functioning once again. Although fluid imbalance may cause difficulty in voiding, there are no data presented to draw this conclusion. A sedentary lifestyle and nervous tension will not cause this problem. Test-Taking Tip: What happens if you find yourself in a slump over the examination? Take a time-out to refocus and reenergize! Talk to friends and family who support your efforts in achieving one of your major accomplishments in life. This effort will help you regain confidence in yourself and get you back on track toward the realization of your long-anticipated goal.
To help prevent a cycle of recurring urinary tract infections, the nurse should plan to instruct a female client to
1 Increase the daily intake of citrus juice
2 Douche regularly with alkaline agents
3 Urinate as soon as possible after intercourse
4 Wipe carefully from back to front - CORRECT ANSWER 3
Intercourse may cause urethral inflammation, increasing the risk of infection; voiding clears the urinary meatus and urethra of microorganisms. Most fruit juices, with the exception of cranberry juice, cause alkaline urine, which promotes bacterial growth. Douching is no longer recommended because it alters the vaginal flora. Perineal care should be accomplished with wipes from the urinary meatus toward the rectum to help prevent microorganisms from the vaginal or rectal areas from reaching the urinary meatus.
The laboratory values of a client with renal calculi reveal a serum calcium within expected limits and an elevated serum purine. The nurse concludes that the stone probably is composed of:
1 Cystine
2 Uric acid
3 Calcium oxalate
4 Magnesium ammonium phosphate - CORRECT ANSWER 2
Purines are precursors of uric acid, which crystallizes. Cystine stones are caused by a rare hereditary defect resulting in inadequate renal tubular reabsorption of cystine (inborn error of cystine metabolism). Serum purine will not be elevated if the stone is composed of calcium oxalate. A struvite stone sometimes is called a magnesium ammonium phosphate stone and is precipitated by recurrent urinary tract infections with coliform bacteria
A nurse is planning to administer a prescribed intravenous solution that contains potassium chloride. What assessment should be brought to the health care provider's attention before administration of the intravenous (IV) line?
1 Uncharacteristic irritability
2 Poor tissue turgor with tenting
3 Urinary output of 200 mL during the previous 8 hours
4 Oral fluid intake of 300 mL during the previous 12 hours - CORRECT ANSWER 3
Decreased urinary output will result in the retention of potassium, causing hyperkalemia. Reporting uncharacteristic irritability is unnecessary; this is a sign of dehydration, which can be corrected with appropriate hydration. Reporting poor tissue turgor with tenting is unnecessary; this may indicate dehydration, which is probably the rationale for the fluid prescribed. Reporting an oral fluid intake of 300 mL during the previous 12 hours is unnecessary; this can precipitate dehydration or can compound an existing dehydration, which can be treated with appropriate hydration.
A nurse is notified that the latest potassium level for a client in acute renal failure is 6.2 mEq. What action should the nurse take?
1 Alert the cardiac arrest team
2 Call the laboratory to repeat the test
3 Take vital signs and notify the primary health care provider
4 Obtain an ECG strip and obtain an antiarrhythmic medication - CORRECT ANSWER 3
Vital signs monitor the cardiopulmonary status; the health care provider must treat this hyperkalemia to prevent cardiac dysrhythmias. The cardiac arrest team responds to a cardiac arrest; there is no sign of arrest in this client. A repeat laboratory test will take time and probably reaffirm the original results; the client needs medical attention. Obtaining an ECG strip and having an antiarrhythmic available are correct interventions if available, but the priority is medical attention and the health care provider should be notified immediately.
The nurse recalls that what scientific principle is basic to caring for a client with an indwelling urinary catheter?
1 Inertia
2 Gravity
3 Osmosis
4 Diffusion - CORRECT ANSWER 2
An indwelling urinary catheter always is positioned so that the level of the bladder is higher than the level of the drainage container; gravity promotes urine flow. Inertia refers to a property of matter. Osmosis refers to the movement of water across a semipermeable membrane; it is not responsible for the flow of urine through a catheter. Diffusion refers to the passage of molecules from an area of higher concentration to one of lower concentration.
Content Area - Medic
A 40-year-old client scheduled for a hemi-colectomy because of ulcerative colitis asks if having a hemi-colectomy means wearing a pouch and having bowel movements in an abnormal way. Which is the best response by the nurse?
1 "Yes, hemi-colectomy is the same as a colostomy."
2 "Yes, but it will be temporary until the colitis is cured."
3 "No, that is necessary when a tumor is blocking the rectum."
4 "No, only part of the colon is removed and the rest reattached." - CORRECT ANSWER 4
Hemi-colectomy is removal of part of the colon with an anastomosis between the ileum and transverse colon; a colostomy is not necessary. With a colostomy the intestine opens on the abdomen, whereas in a hemi-colectomy a portion of the intestine is resected and the ends reconnected. "Yes, but it will be temporary until the colitis is cured" is the description of a temporary colostomy; a cure occurs only when the entire colon is removed. A colostomy is done for a variety of reasons other than a tumor; a colectomy with a colostomy is only one intervention that may be used to treat a tumor.
The nurse provides discharge instructions to a male client that had a ureterolithotomy. The client has a history of recurrent urinary tract infections (UTIs). The teaching should include that indicators of a UTI are:
1 Urgency or frequency of urination
2 The inability to maintain an erection
3 Pain radiating to the external genitalia
4 An increase in the alkalinity of the urine - CORRECT ANSWER 1
Urgency or frequency of urination occur with a urinary tract infection because of bladder irritability; burning on urination and fever are additional signs of a UTI. The inability to maintain an erection is not related to a UTI. Pain radiating to the external genitalia is a symptom of a urinary calculus, not infection. An increase in alkalinity or acidity of urine is not a sign of a UTI; this may be caused by altering the diet to include foods that form acid ash or alkaline ash.
A client is admitted to the hospital from the emergency department with a diagnosis of urolithiasis. The nurse reviews the client's clinical record and performs an admission assessment. What is the priority nursing action?
1 Strain the client's urine.
2 Administer the prescribed morphine.
3 Place in the high-Fowler position.
4 Collect a urine specimen for culture and sensitivity.
00:00:26 - CORRECT ANSWER 2
Pain relief is the priority. Clients report that ureteral colic is excruciatingly painful. Once pain is under control and the client is comfortable, other medical and nursing interventions can be implemented. Although straining all urine is required, pain relief is the priority. Once the client is medicated for pain, the urine that was set aside can be strained. The high-Fowler position is not necessary. The client can be assisted to assume a position of comfort. The urine was sent for a culture and sensitivity in the emergency department.
A female client has a history of recurrent urinary tract infections. What should the nurse include in the teaching plan when teaching the client about health practices that may help decrease future urinary tract infections?
1 Wear cotton underpants.
2 Void at least every 6 hours.
3 Increase alkaline ash foods in the diet.
4 Wipe from back to front after toileting - CORRECT ANSWER 1
Cotton allows air to circulate and does not retain moisture the way synthetic fabrics do; microorganisms multiply in warm, moist environments. Drinking 3 L of fluids a day and voiding every 2 hours help to flush ascending microorganisms from the bladder, thereby reducing the risk for urinary tract infections. Foods high in acid, not alkaline, ash help to acidify urine; this urine is less likely to support bacterial growth. Wiping from back to front after toileting may transfer bacteria from the perianal area toward the urinary meatus, which will increase the risk for urinary tract infection.
Trimethoprim-sulfamethoxazole (Septra) is prescribed for a client with cystitis. When teaching about the medication, the nurse instructs the client to:
1 Drink 8 to 10 glasses of water daily
2 Drink two glasses of orange juice daily
3 Take the medication with meals
4 Take the medication until symptoms subside - CORRECT ANSWER 1
A urinary output of at least 1500 mL daily should be maintained to prevent crystalluria (crystals in the urine). Orange juice produces an alkaline ash, which results in an alkaline urine that supports the growth of bacteria. Trimethoprim-sulfamethoxazole should be taken one hour before meals for maximum absorption. A prescribed course of antibiotics must be completed to eliminate the infection, which can exist on a subclinical level after symptoms subside.
Test-Taking Tip: Multiple-choice questions can be challenging, because students think that they will recognize the right answer when they see it or that the right answer will somehow stand out from the other choices. This is a dangerous misconception. The more carefully the question is constructed, the more each of the choices will seem like the correct response.
A client is admitted to a medical unit with the diagnosis of acute kidney failure. The nurse reviews the client's laboratory data, performs a physical assessment, and obtains the client's vital signs. What should the nurse conclude the client is most likely experiencing? (T 98.9, P 78, R 20, BP 180/100, C/0 NAUSEA, DIARRHEA, ABDOMAINAL PAIN, MUSCLE WEAKENESS. POTASSIUM 5,8 mEq/L, SODIUM 140 mEq/L, CALCIUM 9.0)
1 Hyperkalemia
2 Hyponatremia
3 Hypouricemia
4 Hypercalcemia - CORRECT ANSWER 1
Damaged kidneys are unable to excrete potassium, resulting in hyperkalemia. Potassium, part of the sodium-potassium pump, is involved with muscle contraction. The clinical manifestations indicate hyperkalemia. The expected serum level of potassium is 3.5 to 5.5 mEq/L. Hyponatremia generally is not associated with acute renal failure; hyponatremia is associated with headache, muscle weakness, apathy, and abdominal cramps, not with an irregular pulse or diarrhea. The expected serum level of sodium is 136 to 145 mEq/L. With acute kidney failure the serum sodium may be normal, increased, or decreased. Hypouricemia will not occur, because serum uric acid is increased in clients with kidney failure. Hypercalcemia is not associated with the assessment data listed in the scenario. The expected serum calcium level is 9.0 to 10.5 mg/dL. The serum calcium level with acute kidney failure may be slightly decreased.
A client is scheduled to have an indwelling urinary catheter inserted before abdominal surgery. The nurse should insert the catheter in what location in the illustration?
1 a
2 b
3 c
4 d - CORRECT ANSWER B
B is the urethral orifice, which anatomically is between the clitoris and the vagina; it is the opening into the urethra, the tubular structure that drains urine from the bladder. A is the clitoris, which is situated beneath the anterior commissure, partially hidden between the anterior extremities of the labia minora. C is the opening of the vagina; it is the part of the female genitalia that forms a canal from the vaginal orifice through the vestibule to the uterine cervix. D is the anus; it is the terminal end of the anal canal that is connected to the rectum; the rectum is a portion of the large intestine that is between the anal canal and the descending sigmoid colon. Test-Taking Tip: Multiple-choice questions can be challenging, because students think that they will recognize the right answer when they see it or that the right answer will somehow stand out from the other choices. This is a dangerous misconception. The more carefully the question is constructed, the more each of the choices will seem like the correct response.
A client who is diagnosed with sexual dysfunction makes a comment to the nurse, "Well, I guess my sex life is over." What is the most appropriate response by the nurse?
1 "I'm sorry to hear that."
2 "Oh, you have a lot of good years left."
3 "You are concerned about your sex life?"
4 "Have you asked your health care provider about that?" - CORRECT ANSWER 3
The response "You are concerned about your sex life?" explores the meaning of the statement and allows further expression of concern. The response "I'm sorry to hear that" does not allow an explanation of feelings and cuts off communication. The response "Oh, you have a lot of good years left" lacks both empathy and understanding; it also cuts off communication. The response "Have you asked your health care provider about that?" shirks responsibility; the client may be embarrassed to ask the health care provider and needs the nurse to act as facilitator.
A nurse is assessing the urine of a client with a urinary tract infection. What appearance should the nurse expect this client's urine to have?
1 Smoky
2 Cloudy
3 Orange-amber
4 Yellow-brown - CORRECT ANSWER 2
Cellular debris, white blood cells, bacteria, and pus can cause the urine to become cloudy. Dark, smoky urine usually suggests hematuria. Orange-amber color of urine may indicate concentrated urine; also, it can be caused by phenazopyridine (Pyridium) or foods such as beets. Yellow-brown to olive green color of urine indicates excessive bilirubin.
A female client who has recurrent urinary tract infections (UTIs) is inquiring about the prevention of future UTIs. What information should the nurse include when teaching the client? (Select all that apply.)
1 Avoid fluid intake after 6 pm
2 Drink 8 to 10 glasses of water each day
3 Urinate immediately after sexual intercourse
4 Increase the daily intake of carbonated beverages
5 Clean the perineal area with an astringent soap twice a day - CORRECT ANSWER 2 & 3
Drinking 8 to 10 glasses of water spaced throughout the day flushes the urinary tract and minimizes urinary stasis. Urination flushes the urethra and urinary meatus, limiting the presence of microorganisms. Limiting fluid intake contributes to stasis of urine. Carbonated and caffeinated beverages irritate the bladder and should be avoided. Cleaning the perineum with harsh soaps is irritating to the skin and mucous membranes, and can contribute to the development of UTIs in susceptible women.
The nurse should ask the client with secondary syphilis about sexual contacts during the past:
1 21 days
2 30 days
3 Three months
4 Six months - CORRECT ANSWER 4
The client is in the secondary stage, which begins from six weeks to six months after primary contact; therefore, a six-month history is needed to ensure that all possible contacts are located. Any time less than six months may miss contacts that may have become infected.
A client weighed 210 pounds on admission to the hospital. After two days of diuretic therapy, the client weighs 205.5 pounds. How many liters of fluid has the client excreted? Record the answer using a whole number. Record your answer using a whole number. __________ liters - CORRECT ANSWER One liter of fluid weighs approximately 2.2 pounds; therefore, a 4.5-pound weight loss equals approximately 2 liters.
A client with uremic syndrome has the potential to develop many complications. Which complication should the nurse anticipate?
1 Hypotension
2 Hypokalemia
3 Flapping hand tremors
4 Elevated hematocrit values - CORRECT ANSWER 3
An elevation in uremic waste products causes irritation of the nerves, resulting in flapping hand tremors (asterixis, "liver flap"). Hypertension results from kidney failure because of sodium and water retention. The diseased kidney is unable to excrete potassium ions, resulting in hyperkalemia, not hypokalemia. The hematocrit value will be low because of a decreased production of erythropoietin, a hormone synthesized in the kidney; erythropoietin regulates the production of erythrocytes. STUDY TIP: You have a great resource in your classmates. We all have different learning styles, strengths, and perspectives on the material. Participating in a study group can be a valuable addition to your nursing school experience.
A client is admitted to the hospital for acute gastritis and ascites secondary to alcoholism and cirrhosis. It is most important for the nurse to assess this client for:
1 Blood in the stool
2 Food intolerances
3 Complaints of nausea
4 Hourly urinary output - CORRECT ANSWER 1 [Show Less]