Exhibits

Use an X for the nursing actions listed below that are Indicated (appropriate or necessary), Contraindicated (could be harmful), or Nonessential (makes no difference or not necessary) for the patient's care at this time. Only one selection can be made for each nursing action.

Assess for the presence of bowel sounds every 4 hours

Medicate with ibuprofen every 6 hours as needed for complaint of pain.

Carefully consider the type, frequency, and dosage of the patient's prescribed antibiotic therapy.

Focus on providing holistic nursing care to patient.

Obtain daily weights.

Consult with dietician to provide a low caloric diet.

Answer and Explanation

The Correct Answer is {"A":{"answers":"C"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"C"}}

Assessing for bowel sounds every 4 hours is nonessential in this case since the patient’s primary problem is pyelonephritis with acute kidney injury. Bowel sounds are not directly affected by this condition, so frequent monitoring adds little benefit to her care at this time.
Administering ibuprofen is contraindicated because NSAIDs reduce renal blood flow by inhibiting prostaglandins, which can worsen acute kidney injury. Alternative pain control methods should be used to avoid further kidney damage.
Carefully considering the type, frequency, and dosage of antibiotics is indicated because impaired kidney function affects drug metabolism and clearance. Adjusting antibiotic therapy prevents drug accumulation and ensures effectiveness against the infection.
Focusing on holistic nursing care is indicated since the patient is disoriented, anxious, and has her daughter present. Addressing emotional, psychological, and family support needs promotes overall well-being alongside medical management.
Obtaining daily weights is indicated because weight changes reflect fluid retention or loss, which is critical in monitoring renal function and guiding fluid management in acute kidney injury.
Consulting with a dietician for a low caloric diet is nonessential because the primary nutritional focus in kidney injury is adjusting protein, electrolytes, and fluid intake rather than caloric restriction. A low-calorie diet could even be harmful if it impairs recovery.

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Correct Answer is B

Explanation

A. "You can eat a full liquid meal up to 1 hour before the procedure": Most cystoscopy procedures require the patient to have an empty bladder or follow specific fasting instructions depending on anesthesia use. Eating a full liquid meal shortly before may not be recommended.

B. "You may have pink-tinged urine after this procedure": Mild hematuria or pink-tinged urine is a common and expected finding after a cystoscopy due to minor trauma to the urinary tract during the procedure. This information helps prepare the client and reduces anxiety about normal post-procedure changes.

C. "You should limit fluids for 12 hr following the procedure": Clients are generally encouraged to increase fluid intake after cystoscopy to flush the urinary tract and reduce irritation. Limiting fluids is not indicated and could worsen discomfort or urinary stasis.

D. "You will be placed on your right side during the procedure": Cystoscopy is typically performed with the patient in a supine or lithotomy position to allow proper visualization of the urethra and bladder. Right-side positioning is not standard practice for this procedure.

A. Diuretic use B. BMI less than 25 C. Family history D. Hypocalcemia

Correct Answer is C

Explanation

A. Diuretic use: Some diuretics, particularly thiazides, are actually prescribed to prevent calcium stone formation by reducing urinary calcium excretion. Diuretic use is not considered a primary risk factor for urolithiasis.

B. BMI less than 25: A lower BMI is not linked with kidney stone formation. In fact, higher BMI and obesity are more commonly associated with an increased risk due to metabolic changes that affect urine composition.

C. Family history: A positive family history significantly increases the risk of developing urolithiasis. Genetic predisposition and shared environmental factors contribute to stone formation, making this a strong and well-established risk factor.

D. Hypocalcemia: Urolithiasis is often associated with hypercalcemia or hypercalciuria, which increase the concentration of calcium in urine and promote stone development. Hypocalcemia does not contribute to stone formation and is not a risk factor.

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Exhibits Use an X for the nursing actions listed below that are Indicated (appropriate or necessary), Contraindicated (could be harmful), or Nonessential (makes no difference or not necessary) for the patient's care at this time. Only one selection can be made for each nursing action.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a client who is scheduled for a cystoscopy. Which of the following information should the nurse include in the teaching?

Correct Answer is B

Explanation

A nurse is caring for a client who has a new diagnosis of urolithiasis. Which of the following should the nurse identify as an associated risk factor

Correct Answer is C

Explanation

A nurse is providing discharge teaching for a client who is to perform peritoneal dialysis at home. Which of the following information should the nurse include?

A patient who has increased blood urea nitrogen (BUN) and serum creatinine levels is scheduled for a renal arteriogram. Which bowel preparation order would the nurse question for this patient?

A nurse is caring for a client who has chronic glomerulonephritis. The nurse should expect to find a decrease in which of the following serum laboratory values?

A nurse is caring for a client who has paraplegia following an automobile accident. The client is on an intermittent urinary catheterization program. Which of the following findings indicates the need for catheterization?

A nurse is planning care for a client who has urolithiasis. Which of the following actions should the nurse take?

A patient with a history of polycystic kidney disease is admitted to the surgical unit after having shoulder surgery. Which of the routine postoperative orders is most important for the nurse to discuss with the health care provider?

Which assessment finding is most important to report to the health care provider regarding a patient who has had left-sided extracorporeal shock wave lithotripsy?

Exhibits

Use an X for the nursing actions listed below that are Indicated (appropriate or necessary), Contraindicated (could be harmful), or Nonessential (makes no difference or not necessary) for the patient's care at this time. Only one selection can be made for each nursing action.