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:
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Solution
Check the client’s pedal pulses frequently.
After renal angiography involving a femoral puncture site, the nurse should check the client’s 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.
Option A: The client should be kept on bed rest for several hours so the puncture site can seal completely. Keeping the client’s knee bent is unnecessary.
Option B: By the time the client returns to the short-procedure unit, manual pressure over the puncture site is no longer needed because a pressure dressing is in place.
Option D: The nurse shouldn’t remove this dressing for several hours — and only if instructed to do so.
A male client is scheduled for a renal clearance test. Nurse Sheldon should explain that this test is done to assess the kidneys’ ability to remove a substance from the plasma in:
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Solution
1 minute.
The renal clearance test determines the kidneys’ ability to remove a substance from the plasma in 1 minute. It doesn’t measure the kidneys’ ability to remove a substance over a longer period.
Nurse Pete is reviewing the report of a client’s routine urinalysis. Which value should the nurse consider abnormal?
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Solution
Urine pH of 3.0
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 client’s 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.
Nurse Lily is assessing a male client diagnosed with gonorrhea. Which symptom most likely prompted the client to seek medical attention?
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Solution
Foul-smelling discharge from the penis
Symptoms of gonorrhea in men include purulent, foul-smelling drainage from the penis and painful urination.
Option A: Rashes on the palms of the hands and soles of the feet are symptoms of the secondary stage of syphilis.
Option B: Cauliflower-like warts on the penis are a sign of human papillomavirus.
Option C: Painful red papules on the shaft of the penis may be a sign of the first stage of genital herpes.
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:
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Solution
Weight loss.
Because CRF causes loss of renal function, the client with this disorder retains fluid. Hemodialysis removes this fluid, causing weight loss.
Option A: Hematuria is unlikely to follow hemodialysis because the client with CRF usually forms little or no urine.
Option C: Hemodialysis doesn’t increase urine output because it doesn’t correct the loss of kidney function, which severely decreases urine production in this disorder.
Option D: By removing fluids, hemodialysis decreases rather than increases the blood pressure.
The nurse is aware that the following laboratory values supports a diagnosis of pyelonephritis?
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Solution
Pyuria
Pyelonephritis is diagnosed by the presence of leukocytosis, hematuria, pyuria, and bacteriuria.
Option B: Ketonuria indicates a diabetic state.
Option D: 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.
A male client with bladder cancer has had the bladder removed and an ileal conduit created for urine diversion. While changing this client’s pouch, the nurse observes that the area around the stoma is red, weeping, and painful. What should Nurse Kaye conclude?
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Solution
The pouch faceplate doesn’t fit the stoma.
If the pouch faceplate doesn’t 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.
Option A: A lubricant shouldn’t be used because it would prevent the pouch from adhering to the skin.
Option C: When properly applied, a skin barrier prevents skin excoriation.
Option D: Stoma dilation isn’t performed with an ileal conduit, although it may be done with a colostomy if ordered.
A female client has just been diagnosed with condylomata acuminata (genital warts). What information is appropriate to tell this client?
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Solution
This condition puts her at a higher risk for cervical cancer; therefore, she should have a Papanicolaou (Pap) smear annually.
Women with condylomata acuminata are at risk for cancer of the cervix and vulva. Yearly Pap smears are very important for early detection.
Option B: Because condylomata acuminata is a virus, there is no permanent cure.
Option C: Because condylomata acuminata can occur on the vulva, a condom won’t protect sexual partners. Option D: HPV can be transmitted to other parts of the body, such as the mouth, oropharynx, and larynx.
Option C: Because condylomata acuminata can occur on the vulva, a condom won’t protect sexual partners.
Option D: HPV can be transmitted to other parts of the body, such as the mouth, oropharynx, and larynx.
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?
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Solution
The client keeps the drainage bag below the bladder at all times.
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. Option A: The client shouldn’t lay the drainage bag on the floor because it could become grossly contaminated. Option C: The client shouldn’t clamp the catheter drainage tubing because this impedes the flow of urine. Option D: To promote drainage, the client may loop the drainage tubing above — not below — its point of entry into the drainage bag.
Option A: The client shouldn’t lay the drainage bag on the floor because it could become grossly contaminated.
Option C: The client shouldn’t clamp the catheter drainage tubing because this impedes the flow of urine
Option D: To promote drainage, the client may loop the drainage tubing above — not below — its point of entry into the drainage bag.
The nurse is aware that the following findings would be further evidence of a urethral injury in a male client during rectal examination?
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Solution
The presence of a boggy mass
When the urethra is ruptured, a hematoma or collection of blood separates the two sections of the urethra. This may feel like a boggy mass on rectal examination.
Option A: Because of the rupture and hematoma, the prostate becomes high riding. A palpable prostate gland usually indicates a non-urethral injury.
Option C: Absent sphincter tone would refer to a spinal cord injury.
Option D: The presence of blood would probably correlate with GI bleeding or a colon injury.