Question 5201)
A urinalysis reveals white cells and bacteria in the urine of a female client
suspected of having a bladder infection. The client is instructed to take the prescribed antiinfective. What else should the nurse include when teaching the client?
A. Limit fluid intake until the pain subsides
B. Wipe from back to front after voiding
C. Empty her bladder immediately after having sexual relations
D. Take the medication until she is pain free for 48 hours
Answer: C
Explanation: Failure to empty the bladder after sexual relations is thought to be a cause of bladder infections.
Fluids should be encouraged, not restricted. She should wipe from front to back to prevent rectal organisms from
entering the bladder, also thought to be a cause of bladder infections. All of the medication should be taken to
adequately treat the infection and to prevent the development of resistant organisms.
Question 5202)
An adult male is admitted with severe right flank pain, nausea, and vomiting of
four hours in duration. The admitting diagnosis is a kidney stone. Orders include to encourage
fluids to 1000 cc per shift. What is the primary reason for encouraging fluids in this client?
A. To prevent renal failure
B. To help the stone pass
C. To prevent infection
D. To relieve his dehydration
Answer: B
Explanation: Encouraging fluids will often help the stone to pass. The client in this question has a kidney stone;
there is no mention of impending renal failure. High fluid intake is advised for clients who have bladder infections.
However, that is not the diagnosis for this client. Increasing fluid intake may be indicated for a client who is
dehydrated; however, that is not the diagnosis for this client.
Question 5203)
The nurse is straining the urine of a client admitted with possible renal calculi. A
small stone is discovered. What should the nurse do?
A. Send the stone to the laboratory for analysis
B. Immediately test for guaiac
C. Test the stone for glucose
D. Administer pain medication
Answer: A
Explanation: The stone should be sent to the laboratory for analysis to determine the type of stone. This will help
to determine the diet he should follow. Stones do not usually contain blood or glucose. The laboratory needs to do
the analysis. Passing the stone may be painful, but the pain is usually relieved after the stone is passed.
Question 5204)
A client who has kidney stones complains of pain. The nurse finds him pacing the
hall. What is the most appropriate action for the nurse to take?
A. Tell him to get back in bed where he will be more comfortable
B. Encourage him to walk if it helps to relieve the pain
C. Remind him to walk only when he has someone with him
D. Put him back in bed immediately and position him in semi-sitting position
Answer: B
Explanation: Walking often helps to relieve the pain and will help the stone to pass. The nurse would instruct the
client to have assistance with walking only if he is sedated from pain medication.
Question 5205)
The nurse is caring for a client who has acute renal failure. His potassium rises to
7.3 mEq/L. A Kayexalate enema is ordered. What is the primary purpose of the Kayexalate enema?
A. To remove fluid from the extracellular spaces
B. To exchange potassium ions for sodium ions
C. To reduce abdominal pressure
D. To introduce potassium into the bowel
Answer: B
Explanation: The client’s potassium is dangerously high. The normal range is 3.5 to 5.0 mEq/L. Kayexalate is a
sodium-potassium exchange resin. It removes potassium from the bloodstream. Although it will not correct the
underlying problem, it will lower the serum potassium to safer levels and perhaps prevent serious or even fatal
cardiac dysrhythmias. Kayexalate does not remove fluid or reduce abdominal pressure. Kayexalate does not
introduce potassium into the bowel. A client who has hyperkalemia does not need additional potassium.
Question 5206)
The nurse is caring for a client who is in acute renal failure. Which of the following
selections would be best to give for a snack?
A. A slice of watermelon
B. Orange juice
C. A turkey sandwich
D. A dish of applesauce
Answer: D
Explanation: A client in acute renal failure is on a lowsodium, low-protein, low-potassium, highcarbohydrate diet.
Applesauce is all of these. Watermelon and orange juice are high in potassium. Turkey contains protein, and the
bread contains sodium.
Question 5207)
A 67-year-old man is admitted with dysuria that has gotten worse over the past six
months. Rectal examination revealed an enlarged prostate. Following urination, he was
catheterized and found to have 250 cc of thick, foul-smelling, residual urine. He is admitted with
a diagnosis of benign prostatic hypertrophy. Which symptom is least likely to be present in this
client?
A. Urinary frequency
B. Pus in the urine
C. Dribbling
D. Decreased force of urinary stream
Answer: B
Explanation: BPH causes retention, urinary frequency, dribbling, and decreased force of the urinary stream. It does
not cause pus in the urine. If pyuria (pus in the urine) is present, this indicates a secondary infection.
Question 5208)
The client who has urinary retention has had an indwelling catheter inserted.
Which action is not appropriate for the nurse to take?
A. Limit the client’s fluid intake
B. Monitor blood pressure frequently
C. Weigh the client daily
D. Assess renal function
Answer: A
Explanation: Fluid intake should be encouraged to help prevent the development of a urinary tract infection. It is
not appropriate to limit fluid intake. Following the removal of urine from a distended bladder, there is a risk of
shock. The nurse should monitor the blood pressure. The nurse should weigh the client daily to assess for fluid
retention. The nurse would assess renal function by monitoring intake and output.
Question 5209)
The nurse has inserted an indwelling catheter into an adult male. The nurse tapes
the urinary drainage tube laterally to the thigh for which of the following reasons?
A. To ensure client comfort
B. To prevent reflux of urine
C. To maintain tension on the balloon of the Foley
D. To prevent compression at the penoscrotal junction
Answer: D
Explanation: Compression at the penoscrotal junction will cause obstruction of urine flow. Taping the catheter to
the thigh straightens out the urethra and prevents compression of the penoscrotal junction. Leaving the penis in a
dependent position increases pressure at the penoscrotal junction. Taping the catheter to the thigh does not
prevent the reflux of urine. Keeping the tubing gently sloping in a downward direction will help to prevent reflux.
There is no need to maintain tension on the balloon of the indwelling catheter. If the balloon is inflated and
positioned properly, it will stay in position. The client may or may not be more comfortable with the catheter in
this position. However, comfort is not the reason for taping the catheter to the thigh.
Question 5210)
A client who had a transurethral prostatectomy is returned to the unit with
continuous bladder irrigation. The nurse understands that the primary purpose of continuous
bladder irrigation for this client is to:
A. prevent a urinary tract infection.
B. maintain bladder tone.
C. prevent clots in the bladder
D. prevent urethral stricture
Answer: C
Explanation: Continuous bathing of the bladder with the irrigating solution will prevent formation of clots in the
bladder. The primary purpose of continuous bladder irrigation (CBI) is not to prevent urinary tract infection. CBI
does not maintain bladder tone. When a client has CBI, the client has an indwelling catheter. CBI does not prevent
urethral stricture formation.
Question 5211)
A 35-year-old man asks the nurse about a vasectomy. In discussing a vasectomy
with this man, which information is most important to provide?
A. A vasectomy involves tubal ligation done by surgery
B. This is a permanent method of contraception
C. The surgery takes approximately one hour
D. A vasectomy may cause intermittent impotence.
Answer: B
Explanation: A vasectomy is considered a permanent method of contraception even though it is occasionally
possible to reverse. A vasectomy is essentially a ligation of the tube (vas deferens) and is done by surgery, so
answer 1 is a true statement. However, the information in answer 2, that this is a permanent method of
sterilization, is much more essential. A vasectomy causes sterility but not impotence (inability to maintain an
erection); it does not interfere with sexual functioning. The procedure does not take an hour; it takes only a few
minutes.
Question 5212)
A client asks the nurse if he can get his wife pregnant after a vasectomy. What is
the best response for the nurse to make?
A. “No. The procedure works immediately and is permanent.”
B. “The first few ejaculations after a vasectomy contain active sperm.”
C. “Yes. You should continue to practice birth control for six months.”
D. “No. The doctor will flush the sperm out after the procedure is completed.”
Answer: B
Explanation: The first few ejaculations contain sperm that are already in the tubes. Before he is considered sterile,
he should have two ejaculates a month apart that test sperm free. It is usually at least six to eight weeks before a
man is considered sterile following a vasectomy. The surgeon does not flush the sperm from the man’s tubes.
Question 5213)
A client asks the nurse if he will be able to ejaculate after the vasectomy is done.
What is the best response for the nurse to make?
A. “Yes. This procedure does not affect the ejaculate.”
B. “No. The purpose of a vasectomy is to prevent ejaculation.”
C. “Are you concerned about your sexual identity?”
D. “My husband had a vasectomy and it doesn’t bother us
Answer: A
Explanation: A vasectomy does not prevent ejaculation. The ejaculate does not contain sperm. The man’s sexual
functioning is not affected. The client asks for information. The most appropriate response is to give the
information. There is no evidence in the question that the man is concerned about his sexual identity. The nurse
should answer the client’s question, not interject her own experience in answering this question
Question 5214)
An Adult was on bed rest for several weeks. A nursing care goal is to prevent the
formation of renal calculi. Which of the following liquids is it especially important to include in the
client’s diet?
A. Tomato juice
B. Coffee
C. Cranberry juice
D. Milk
Answer: C
Explanation: Most urinary calculi that form as a result of prolonged immobility are alkaline. Cranberry juice leaves
an acid ash, which keeps the urine acidic. The other liquids leave an alkaline ash, which could lead to the
development of calculi.
Question 5215)
The physician has prescribed a diuretic for an adult client. Which nursing
intervention is most important in relation to diuretic therapy?
A. Test the urine for sugar and acetone
B. Measure daily weights
C. Maintain accurate intake and output
D. Assess for pedal edema
Answer: B
Explanation: A diuretic causes increased urine output. Monitoring daily weights is the best way to assess changes in
hydration status. Testing urine for sugar and acetone is not indicated for this client. There are no data stating that
the client is a diabetic. Intake and output may be indicated, but daily weights will give a more reliable indication of
actual fluid loss. It is not wrong to assess for pedal edema, but daily weights will give a better indicator of fluid
loss. Edema can be in places other than the feet
Question 5216)
The nurse is caring for an adult who has an indwelling urinary catheter with a
continuous bladder irrigation infusing. How should the nurse calculate the urine output when the
drainage bag is emptied?
A. Subtract the total drainage from the amount of irrigation solution used
B. Measure the amount of drainage and subtract the amount of solution infused
C. Record both the total drainage and the amount of irrigant used on the intake and output record
D. Calculate the total fluid intake and subtract this amount from the total drainage
Answer: B
Explanation: The irrigating solution goes in through the catheter, bathes the bladder, and flows out through the
tubing into the collection bag. The nurse should measure the total amount of drainage and subtract the amount of
irrigating solution infused because this is not urine output. Answer 1 makes no sense because the drainage is larger
than the amount of irrigating solution used. The question asked how the nurse calculates total urine output.
Answer 3 does not address the issue of calculating the total urine output. Recording total fluid intake will most
likely be done for this client, but subtracting it from the drainage does not tell us the client’s urine output.
Question 5217)
The nurse calculates intake and output for an adult client. His intake for the shift
is 1000 mL. The total amount of drainage emptied from the drainage bag is 2550 mL. During the
shift, 1825 mL of genitourinary irrigant has infused. What is the client’s eight-hour urine output?
A. 725 mL
B. 650 mL
C. 825 mL
D. 750 mL
Answer: A
Explanation: Total drainage from the bag is 2550 mL. The amount of irrigant infused is 1825 mL. Subtract 1825 mL
from 2250 mL, and the answer is 725 mL of urine.
Question 5218)
The nurse is caring for a client admitted for treatment of acute
glomerulonephritis. Which question should the nurse ask when obtaining information about the
present illness?
A. “Have you had a sore throat recently?”
B. “Has anyone in your family had chickenpox recently?”
C. “Have you had a bladder infection in the last six weeks?”
D. “Does anyone in your family have a history of kidney disease?”
Answer: A
Explanation: When obtaining a history of the present illness, the nurse questions the client about precipitating
factors. Acute glomerulonephritis (AGN) usually occurs 10 to 14 days after a streptococcal (strep) infection. Strep
throat or strep-related otitis media is the most common precipitating event. Chickenpox is caused by herpes zoster
virus and is not usually associated with AGN. A bladder infection is not usually associated with AGN. AGN follows a
strep infection and is not specifically an inherited condition.
Question 5219)
A 78-year-old man is scheduled for a transurethral resection of the prostate
(TURP) tomorrow morning for treatment of benign prostatic hypertrophy. What instruction should
the nurse give him about the initial postoperative period?
A. “Void every two hours whether or not you feel the urge to do so.”
B. “Get up and walk to decrease discomfort from bladder spasms.”
C. “Cough and deep breathe every two hours to prevent clot formation
D. “Expect cherry-red urine that will gradually turn pink.”
Answer: D
Explanation: It is important to tell the client that his urine will be red during the postsurgical period so that he is
not frightened. The client will have an indwelling urinary catheter after surgery. He may even have a continuous,
normal saline irrigation. There is no need to give instructions regarding voiding until after the catheter has been
removed. Walking does not usually relieve bladder spasms. Coughing and deep breathing are important
postoperative interventions, but they do not prevent clot formation.
Question 5220)
A 35-year-old man is admitted with severe renal colic. The nurse should monitor
this man for possible complications. Which of the following is a complication of renal colic?
A. Anemia
B. Polyuria
C. Hypertension
D. Oliguria
Answer: D
Explanation: Renal colic is severe pain associated with ureteral spasms when the ureter is irritated by a stone. A
stone may occlude the ureter and block urine flow from the kidney. This can also result in hydronephrosis, a
complication that can lead to kidney necrosis. Anemia and hypertension are complications of renal failure. Polyuria
is not associated with renal colic
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