Answers, Rationales, and Test

Taking Strategies
The answers and rationales for each question follow
below, along with keys ( ) to the client need
(CN) and cognitive level (CL) for each question. Use
these keys to further develop your test-taking skills.
For additional information about test-taking skills
and strategies for answering questions, refer to pages
1021, and pages 2526 in Part 1 of this book.

The Client with Cancer of the

Bladder

1.

1, 4. An adequate fl uid intake aids in the

prevention of urinary calculi and infection. Odorproducing
foods can produce offensive odors that
may impact the clients lifestyle and relationships.
Lack of activity leads to urinary stasis, which promotes
urinary calculi development and infection.
Acidic urine helps prevent urinary tract infections.
Tight clothing over the stoma obstructs blood circulation
and urine fl ow.
CN: Reduction of risk potential;
CL: Synthesize

2.

1, 2, 3. Dermatitis with alkaline encrustations

may occur when alkaline urine comes in contact
with exposed skin. Yeast infections (or fungal infections)
are another common peristomal skin problem.
If the stoma is irritated from rubbing, there will be
bleeding. The nurse and client should avoid irritating
the stoma. Adhesive solvent is used on a gauze
pad to remove old adhesive and would not contact
the stoma directly. Only a minimal amount of skin
cement is applied to the faceplate and skin to secure
the appliance over the stoma, so obstruction of the
stoma by the cement would not be possible.
CN: Physiological adaptation;
CL: Evaluate

3.

3. Painless hematuria is the most common

clinical fi nding in bladder cancer. Other symptoms
include urinary frequency, dysuria, and urinary
urgency, but these are not as common as hematuria.
Suprapubic pain and urine retention do not occur in
bladder cancer.
CN: Physiological adaptation;
CL: Analyze

4.

2. Chills could indicate the onset of acute

infection that can progress to septic shock. Dizziness
would not be an anticipated symptom after a
cystoscopy. Pink-tinged urine and bladder spasms
are common after cystoscopy.
CN: Reduction of risk potential;
CL: Analyze

5.

4. Lower abdominal pain after a cystoscopy

is frequently caused by bladder spasms. Warm water
can help relax muscles. Ice is not effective in relieving
spasms. Massage and ambulation may increase
bladder irritability.
CN: Basic care and comfort;
CL: Synthesize

6.

3. An ileal conduit is a permanent urinary

diversion in which a portion of the ileum is surgically
resected and one end of the segment is closed.
The ureters are surgically attached to this segment
of the ileum, and the open end of the ileum
is brought to the skin surface on the abdomen to
form the stoma. The client must wear a pouch to
collect the urine that continually fl ows through the
conduit. The bladder is removed during the surgical
procedure and the ileal conduit is not reversible.
Diversion of urine to the sigmoid colon is
called a ureteroileosigmoidostomy. An opening in the bladder that allows urine to drain
externally is
called a cystostomy.
CN: Reduction of risk potential;
CL: Apply

7.

2. After pelvic surgery, there is an increased

chance of thrombophlebitis owing to the pelvic
manipulation that can interfere with circulation
and promote venous stasis. Peritonitis is a potential
complication of any abdominal surgery, not just pelvic
surgery. Ascites is most frequently an indication
of liver disease. Inguinal hernia may be caused by
an increase in intra-abdominal pressure or a congenital
weakness of the abdominal wall; ventral hernia
occurs at the site of a previous abdominal incision.
CN: Reduction of risk potential;
CL: Analyze

8.

4. Mucus is secreted by the intestinal segment

used to create the conduit and is a normal
occurrence. The client should be encouraged to
maintain a large fl uid intake to help fl ush the mucus
out of the conduit. Because mucus in the urine is
expected, it is not necessary to change the appliance
bag or to notify the physician. The mucus is not an
indication of an infection, so a urine culture is not
necessary.
CN: Reduction of risk potential;
CL: Synthesize

9.

4. If the appliance becomes too full, it is

likely to pull away from the skin completely or to
leak urine onto the skin; thus if the seal is intact, the
client is emptying the appliance regularly. The skin
around the seal should not be red or irritated, which
could indicate a leak. There will likely be an odor
from the urine. Deep yellow urine indicates that the

client should be increasing fl uid intake.

CN: Physiological adaptation;
CL: Evaluate

10.

1. Inserting a gauze wick into the stoma helps

prevent urine leakage when changing the appliance.
The stoma should not be sealed or suctioned. Oral
fl uids do not need to be avoided.
CN: Physiological adaptation;
CL: Synthesize

11.

2. A reusable appliance should be routinely

cleaned with soap and water.
CN: Physiological adaptation; CL: Apply

12.

3, 4. The client with an ileal conduit must

learn self-care activities related to care of the stoma
and ostomy appliances. The client should be taught
to increase fl uid intake to about 3,000 mL/day and
should not limit intake. Adequate fl uid intake helps
to fl ush mucus from the ileal conduit. The ostomy
appliance should be changed approximately every
3 to 7 days and whenever a leak develops. A skin
barrier is essential to protecting the skin from the
irritation of the urine. An aspirin should not be used
as a method of odor control because it can be an irritant
to the stoma and lead to ulceration. The ostomy
pouch should be emptied when it is one-third to
one-half full to prevent the weight of the urine from
pulling the appliance away from the skin.
CN: Reduction of risk potential;
CL: Evaluate

13.

2. A distilled vinegar solution acts as a

good deodorizing agent after an appliance has been
cleaned well with soap and water. If the client
prefers, a commercial deodorizer may be used. Salt
solution does not deodorize. Ammonia and bleaching
agents may damage the appliance.
CN: Basic care and comfort; CL: Apply

14.

4. It is normal for clients to express fears

and concerns about the body changes associated
with a urinary diversion. Allowing the client time
to verbalize concerns in a supportive environment
and suggesting that she discuss these concerns with
people who have successfully adjusted to ostomy
surgery can help her begin coping with these
changes in a positive manner. Although the client
may be anxious about this situation and self-esteem
may be diminished, the underlying problem is a
disturbance in body image. There are no data to support
a diagnosis of Defi cient knowledge.
CN: Psychosocial adaptation;
CL: Analyze

15.

1. The most important reason for attaching

the appliance to a standard urine collection bag at
night is to prevent urine refl ux into the stoma and

ureters, which can result in infection. Use of a standard

collection bag also keeps the appliance from
separating from the skin and helps prevent urine
leakage from an overly full bag, but the primary
purpose is to prevent refl ux of urine. A client with a
urinary diversion should drink 2,000 to 3,000 mL of
fl uid each day; it would be inappropriate to suggest
decreasing fl uid intake.
CN: Physiological adaptation; CL: Apply

16.

2. Maintaining a fl uid intake of 2,000 to 3,000

mL/day is likely to be most effective in preventing
urinary tract infection. A high fl uid intake results in
high urine output, which prevents urinary stasis and
bacterial growth. Avoiding people with respiratory
tract infections will not prevent urinary tract infections.
Clean, not sterile, technique is used to change
the appliance. An ileal conduit stoma is not irrigated.
CN: Physiological adaptation;
CL: Synthesize

17.

4. It is important that the client empty the

drainage pouch throughout the day to decrease the
risk of leakage. The client does not normally need
to curtail physical activity. Aspirin should never
be placed in a pouch because aspirin can irritate or
ulcerate the stoma. The client does not catheterize
an ileal conduit stoma.
CN: Physiological adaptation;
CL: Evaluate

18.

1, 3, 4. The nurse should assess the biopsy

site for bleeding and hematoma formation. The client
should remain prone for 8 to 24 hours after the
biopsy. A pressure dressing will aid in blood coagulation.
Vital signs assessment should be taken every
5 to 15 minutes for the fi rst hour and then less often
if the client is stable. The urine does not need to be
collected and kept on ice. The nurse should collect
serial urine specimens to assess for hematuria. A
renal biopsy does not put the client at increased risk
for chest pain.
CN: Reduction of risk potential;
CL: Synthesize

The Client with Renal Calculi

19.

4. If infection or blockage caused by calculi is

present, a client can experience sudden severe pain
in the fl ank area, known as renal colic. Pain from a
kidney stone is considered an emergency situation
and requires analgesic intervention. Withholding
fl uids will make urine more concentrated and stones
more diffi cult to pass naturally. Forcing large quantities
of fl uid may cause hydronephrosis if urine is
prevented from fl owing past calculi. Straining urine
for small stones is important, but does not take priority
over pain management.

CN: Management of care; CL: Synthesize

20.

3. The priority nursing goal for this client

is to alleviate the pain, which can be excruciating.
Prevention of urinary tract complications and
alleviation of nausea are appropriate throughout the
clients hospitalization, but relief of the severe pain
is a priority. The client is at little risk for fl uid and
electrolyte imbalance.
CN: Physiological adaptation;
CL: Synthesize

21.

4. A KUB radiographic examination ordinarily

requires no preparation. It is usually done while
the client lies supine and does not involve the use
of radiopaque substances.
CN: Reduction of risk potential;

22.

2. The pain associated with renal colic due

to calculi is commonly referred to the groin and
bladder in female clients and to the testicles in
male clients. Nausea, vomiting, abdominal cramping,
and diarrhea may also be present. Nephritis or
urine retention is an unlikely cause of the referred
pain. The type of pain described in this situation is
unlikely to be caused by additional stone formation.
CN: Physiological adaptation;
CL: Analyze

23.

2. During episodes of renal colic, the pain

is excruciating. It is necessary to administer opioid
analgesics to control the pain. Application of heat,
encouraging high fl uid intake, and limitation of
activity are important interventions, but they will
not relieve the renal colic pain.
CN: Reduction of risk potential;
CL: Synthesize

24.

2. Intermittent pain that is less colicky

indicates that the calculi may be moving along the
urinary tract. Fluids should be encouraged to promote
movement, and the urine should be strained
to detect passage of the stone. Hematuria is to be
expected from the irritation of the stone. Analgesics
should be administered when the client needs them,
not routinely. Moist heat to the fl ank area is helpful
when renal colic occurs, but it is less necessary as
pain is lessened.
CN: Physiological adaptation;
CL: Synthesize

25.

3. A client scheduled for an IVP should be

assessed for allergies to iodine and shellfi sh. Clients
with such allergies may be allergic to the IVP
dye and be at risk for an anaphylactic reaction.
Adequate fl uid intake is important after the examination.
Bladder spasms are not common during an
IVP. Bowel preparation is important before an IVP
to allow visualization of the ureters and bladder, but

checking for allergies is most important.

CN: Reduction of risk potential;
CL: Synthesize

26.

2. After an IVP, the nurse should encourage

fl uids to decrease the risk of renal complications
caused by the contrast agent. There is no need to
place the client on bed rest or administer a laxative.
An IVP would not cause hematuria.
CN: Reduction of risk potential;
CL: Synthesize

27.

2. The ureteral catheter should drain freely

without bleeding at the site. The catheter is rarely
irrigated, and any irrigation would be done by the
physician. The catheter is never clamped. The
clients total urine output (ureteral catheter plus voiding or indwelling urinary catheter
output)
should be 30 mL/hour.
CN: Reduction of risk potential;
CL: Synthesize

28.

1. Ambulation stimulates peristalsis. A client

with paralytic ileus is kept on nothing-by-mouth
status until peristalsis returns. Carbonated beverages
will increase gas and distention but will not stimulate
peristalsis. A stool softener will not stimulate
peristalsis. I.V. fl uid infusion is a routine postoperative
order that does not have any effect on preventing
paralytic ileus.
CN: Physiological adaptation;
CL: Synthesize

29.

2. The decrease in urine output may refl ect

inadequate renal perfusion and should be reported
immediately. Urine output of 30 mL/hour or greater
is considered acceptable. A slight elevation in temperature
is expected after surgery. Peristalsis returns
gradually, usually the second or third day after
surgery. Bowel sounds will be absent until then. A
small amount of serosanguineous drainage is to be
expected.
CN: Physiological adaptation;
CL: Analyze

30.

1. A high daily fl uid intake is essential for all

clients who are at risk for calculi formation because
it prevents urinary stasis and concentration, which
can cause crystallization. Depending on the composition
of the stone, the client also may be instructed
to institute specifi c dietary measures aimed at
preventing stone formation. Clients may need to
limit purine, calcium, or oxalate. Urine may need to
be either alkaline or acid. There is no need to strain
urine regularly.
CN: Basic care and comfort;
CL: Synthesize

31.

1. Because a high-purine diet contributes

to the formation of uric acid, a low-purine diet is

advocated. An alkaline-ash diet is also advocated
because uric acid crystals are more likely to develop
in acid urine. Foods that may be eaten as desired in
a low-purine diet include milk, all fruits, tomatoes,
cereals, and corn. Foods allowed on an alkaline-ash
diet include milk, fruits (except cranberries, plums,
and prunes), and vegetables (especially legumes and
green vegetables). Gravy, chicken, and liver are high
in purine.
CN: Basic care and comfort;
CL: Evaluate

32.

2. Allopurinol (Zyloprim) is used to treat

renal calculi composed of uric acid. Adverse effects
of allopurinol include drowsiness, maculopapular
rash, anemia, abdominal pain, nausea, vomiting, and bone marrow depression. Clients
should be
instructed to report rashes and unusual bleeding or
bruising. Retinopathy, nasal congestion, and dizziness
are not adverse effects of allopurinol.
CN: Pharmacological and parenteral
therapies; CL: Synthesize

33.

1, 2, 5. Common adverse effects of

allopurinol (Zyloprim) include gastrointestinal
distress, such as anorexia, nausea, vomiting, and
diarrhea. A rash is another potential adverse effect.
A potentially life-threatening adverse effect is bone
marrow depression. Constipation and fl ushed skin
are not associated with this drug.
CN: Pharmacological and parenteral
therapies; CL: Analyze

34.

4. By inhibiting uric acid synthesis,

allopurinol (Zyloprim) decreases its excretion.
The drugs effectiveness is assessed by evaluating
for a decreased serum uric acid concentration.
Allopurinol does not alter the level of alkaline phosphatase,
nor does it affect urine calcium excretion or
the serum calcium level.
CN: Pharmacological and parenteral
therapies; CL: Evaluate

The Client with Acute Renal Failure

35.

4. Solution for peritoneal dialysis should be

warmed to body temperature in a warmer or with
a heating pad; do not use the microwave. Cold
dialysate increases discomfort. Assessment for a
bruit and thrill is necessary with hemodialysis
when the client has a fi stula, graft, or shunt. An
indwelling urinary catheter is not required for this
procedure. The nurse should position the client in a
supine or low Fowlers position.
CN: Reduction of risk potential;
CL: Synthesize

36.

1, 2, 3, 4. Elevation of the head of the bed

will promote ease of breathing. Respiratory manifestations

of acute renal failure include shortness
of breath, orthopnea, crackles, and the potential for
pulmonary edema. Therefore, priority is placed on
facilitation of respiration. The nurse should assess
the vital signs because the pulse and respirations
will be elevated. Establishing a site for I.V. therapy
will become important because fl uids will be administered
I.V. in addition to orally. The physician will
need to be contacted for further orders; there is no
need to contact the hemodialysis unit.
CN: Physiological adaptation;
CL: Synthesize

37.

4. Oliguria is the most common initial symptom

of acute renal failure. Anuria is rarely the initial
symptom. Dysuria and hematuria are not associated
with acute renal failure.
CN: Physiological adaptation;
CL: Analyze

38.

1. There are three categories of acute renal

failure: prerenal, intrarenal, and postrenal. Causes
of prerenal failure occur outside the kidney and
include poor perfusion and decreased circulating
volume resulting from such factors as trauma, septic
shock, impaired cardiac function, and dehydration.
In this case of severe myocardial infarction, there
was a decrease in perfusion of the kidneys caused
by impaired cardiac function. An obstruction
within the urinary tract, such as from kidney stones,
tumors, or benign prostatic hypertrophy, is called
postrenal failure. Structural damage to the kidney
resulting from acute tubular necrosis is called
intrarenal failure. It is caused by such conditions
as hypersensitivity (allergic disorders), renal vessel
obstruction, and nephrotoxic agents.
CN: Physiological adaptation; CL: Apply

39.

4. Urea, an end product of protein metabolism,

is excreted by the kidneys. Impairment in
renal function caused by reduced renal blood fl ow
results in an increase in the plasma urea level. Fluid
retention, hemolysis of red blood cells, and lowered
metabolic rate do not cause an elevated BUN value.
CN: Reduction of risk potential;
CL: Analyze

40.

4. Polystyrene sulfonate, a cation-exchange

resin, causes the body to excrete potassium through
the gastrointestinal tract. In the intestines, particularly
the colon, the sodium of the resin is partially
replaced by potassium. The potassium is then
eliminated when the resin is eliminated with feces.
Although the result is to increase potassium excretion,
the specifi c method of action is the exchange
of sodium ions for potassium ions. Polystyrene
sulfonate does not release hydrogen ions or increase

calcium absorption.
CN: Pharmacological and parenteral
therapies; CL: Apply