Question 1
Multiple Choice
A new graduate nurse and their preceptor must collect several urine specimens for laboratory testing. Which techniques for urine collection by the graduate nurse are performed incorrectly, requiring the preceptor to intervene?
Correct!
Incorrect
The correct answer is: B,C,D
Rationale
Collecting a clean-catch urine specimen in the morning and storing it at room temperature until an afternoon pick-up is performed incorrectly, requiring intervention from the preceptor.
B: Collecting a clean-catch urine specimen in the morning and storing it at room temperature until an afternoon pick-up compromises specimen integrity, leading to potential contamination and inaccurate test results.
C: Collecting a sterile urine specimen from the collection bag of a patient's indwelling catheter results in contamination, as the bag is not a sterile source and can harbor bacteria.
D: Collecting about 3 mL of urine from a patient's indwelling catheter to send for a urine culture fails to meet the volume requirement for reliable culture analysis, risking invalid results.
Correct Answer: B,C,D
Rationale: Collecting a clean-catch urine specimen in the morning and storing it at room temperature until an afternoon pick-up is performed incorrectly, requiring intervention from the preceptor.
B: Collecting a clean-catch urine specimen in the morning and storing it at room temperature until an afternoon pick-up compromises specimen integrity, leading to potential contamination and inaccurate test results.
C: Collecting a sterile urine specimen from the collection bag of a patient's indwelling catheter results in contamination, as the bag is not a sterile source and can harbor bacteria.
D: Collecting about 3 mL of urine from a patient's indwelling catheter to send for a urine culture fails to meet the volume requirement for reliable culture analysis, risking invalid results.
Question 2
Multiple Choice
A nurse caring for older adults in an extended-care facility performs regular assessments of the patients' urinary functioning. Which patients would the nurse identify as at risk for urinary retention?
Correct!
Incorrect
The correct answer is: A,C,E
Rationale
Patients diagnosed with an enlarged prostate, vaginal prolapse, or taking antihistamines are at risk for urinary retention due to anatomical obstructions or medication side effects that hinder normal urinary flow.
B: Patient who is on bedrest Bedrest can contribute to urinary retention, but it does not create the same direct anatomical or physiological barriers as the other options.
D: Older adult patient with dementia While cognitive impairment may affect toileting, it does not inherently cause physiological factors leading to urinary retention like the anatomical issues presented in other options.
F: Patient who has difficulty walking to the bathroom Mobility challenges can influence urinary habits but do not directly cause the physiological blockage associated with urinary retention seen in other selected options.
Correct Answer: A,C,E
Rationale: Patients diagnosed with an enlarged prostate, vaginal prolapse, or taking antihistamines are at risk for urinary retention due to anatomical obstructions or medication side effects that hinder normal urinary flow.
B: Patient who is on bedrest Bedrest can contribute to urinary retention, but it does not create the same direct anatomical or physiological barriers as the other options.
D: Older adult patient with dementia While cognitive impairment may affect toileting, it does not inherently cause physiological factors leading to urinary retention like the anatomical issues presented in other options.
F: Patient who has difficulty walking to the bathroom Mobility challenges can influence urinary habits but do not directly cause the physiological blockage associated with urinary retention seen in other selected options.
Question 3
Multiple Choice
A nurse in the gynecology clinic is preparing an educational brochure to teach patients how to prevent UTIs. Which teaching points would the nurse include?
Correct!
Incorrect
The correct answer is: A,C,D,E
Rationale
A: Wear underwear with a cotton crotch.
Cotton underwear promotes breathability and moisture absorption, reducing bacterial growth and lowering the risk of urinary tract infections. This simple practice enhances comfort and hygiene, essential for patient education.
B: Take baths rather than showers.
Bathing in water can introduce bacteria into the urinary tract, increasing infection likelihood. Showers are preferable for maintaining cleanliness without exposing the urethra to potential contaminants.
C: Drink of six to eight 8-oz glasses of liquid per day.
While hydration is crucial, the specific amount may vary. Patients should focus on drinking enough fluid to promote regular urination, flushing out bacteria rather than adhering to a fixed quantity.
F: Observe the urine for color, amount, odor, and frequency.
Monitoring urine characteristics provides insight into hydration levels and potential infections. However, this practice does not directly prevent UTIs, making it less pertinent for education on prevention strategies.
Correct Answer: A,C,D,E
Rationale: A: Wear underwear with a cotton crotch.
Cotton underwear promotes breathability and moisture absorption, reducing bacterial growth and lowering the risk of urinary tract infections. This simple practice enhances comfort and hygiene, essential for patient education.
B: Take baths rather than showers.
Bathing in water can introduce bacteria into the urinary tract, increasing infection likelihood. Showers are preferable for maintaining cleanliness without exposing the urethra to potential contaminants.
C: Drink of six to eight 8-oz glasses of liquid per day.
While hydration is crucial, the specific amount may vary. Patients should focus on drinking enough fluid to promote regular urination, flushing out bacteria rather than adhering to a fixed quantity.
F: Observe the urine for color, amount, odor, and frequency.
Monitoring urine characteristics provides insight into hydration levels and potential infections. However, this practice does not directly prevent UTIs, making it less pertinent for education on prevention strategies.
Question 4
Regular
A patient who has pneumonia has had a fever for 3 days. What characteristics would the nurse anticipate related to the patient's urine output?
Correct!
Incorrect
The correct answer is: A
Rationale
Decreased amount and highly concentrated.
In pneumonia, fever can lead to dehydration due to increased metabolic demands and fluid loss, prompting the body to conserve water, resulting in reduced urine output that's more concentrated.
B: Decreased amount and very pale like water. This scenario contradicts typical physiological responses, as decreased urine volume during fever would not result in dilute urine but rather concentrated output.
C: Increased amount and very concentrated. Increased urine output typically indicates proper hydration and is not expected during fever, where the body tends to retain fluids and produce less urine.
D: Increased amount and dilute appearing. A state of increased urine output would reflect proper hydration, which is unlikely during a fever associated with pneumonia, where urine tends to be concentrated instead.
Correct Answer: A
Rationale: Decreased amount and highly concentrated.
In pneumonia, fever can lead to dehydration due to increased metabolic demands and fluid loss, prompting the body to conserve water, resulting in reduced urine output that's more concentrated.
B: Decreased amount and very pale like water. This scenario contradicts typical physiological responses, as decreased urine volume during fever would not result in dilute urine but rather concentrated output.
C: Increased amount and very concentrated. Increased urine output typically indicates proper hydration and is not expected during fever, where the body tends to retain fluids and produce less urine.
D: Increased amount and dilute appearing. A state of increased urine output would reflect proper hydration, which is unlikely during a fever associated with pneumonia, where urine tends to be concentrated instead.
Question 5
Regular
The health care provider has ordered an indwelling catheter to be inserted to relieve urinary retention in a male patient with prostate enlargement. What consideration will the nurse keep in mind when performing this procedure?
Correct!
Incorrect
The correct answer is: A
Rationale
The male urethra is more vulnerable to injury during insertion. This anatomical consideration is crucial as the male urethra is longer and has more curves, increasing the risk of trauma and complications during catheterization in patients with prostate enlargement.
B: In the hospital, a clean technique is used for catheter insertion. A sterile technique is essential for catheter placement to prevent infections, making this option inadequate for safe practice.
C: The catheter is inserted 2 to 3 inches into the meatus. The correct insertion depth for male catheters typically exceeds three inches, making this statement misleading and potentially harmful.
D: Since it uses a closed system, the risk for UTI is absent. Although a closed system reduces infection risk, it does not eliminate it entirely, as UTIs can still occur.
Correct Answer: A
Rationale: The male urethra is more vulnerable to injury during insertion. This anatomical consideration is crucial as the male urethra is longer and has more curves, increasing the risk of trauma and complications during catheterization in patients with prostate enlargement.
B: In the hospital, a clean technique is used for catheter insertion. A sterile technique is essential for catheter placement to prevent infections, making this option inadequate for safe practice.
C: The catheter is inserted 2 to 3 inches into the meatus. The correct insertion depth for male catheters typically exceeds three inches, making this statement misleading and potentially harmful.
D: Since it uses a closed system, the risk for UTI is absent. Although a closed system reduces infection risk, it does not eliminate it entirely, as UTIs can still occur.
Question 6
Regular
A nurse is caring for a patient with an enlarged prostate who has had an indwelling catheter for several weeks. A prescription for continuous bladder irrigation (CBI) is written after the patient developed hematuria post cystoscopy. The nurse teaches the patient the purpose of CBI is to prevent what situation?
Correct!
Incorrect
The correct answer is: C
Rationale
Continuous bladder irrigation (CBI) is intended to prevent blood clots that could block the catheter. This is crucial for maintaining proper urine flow and avoiding complications following the cystoscopy procedure.
A: Catheter infection due to long-term use. While catheter use can lead to infections, CBI specifically addresses immediate concerns related to blood clots after cystoscopy, not infections.
B: Need to flush the catheter of organisms post procedure. Though flushing might help with organisms, CBI primarily focuses on preventing clots from obstructing urine flow, which is the priority here.
D: Need for increased fluid intake. Increased fluid intake may support general urinary health, but CBI's primary goal is to manage bleeding complications and maintain catheter patency after the procedure.
Correct Answer: C
Rationale: Continuous bladder irrigation (CBI) is intended to prevent blood clots that could block the catheter. This is crucial for maintaining proper urine flow and avoiding complications following the cystoscopy procedure.
A: Catheter infection due to long-term use. While catheter use can lead to infections, CBI specifically addresses immediate concerns related to blood clots after cystoscopy, not infections.
B: Need to flush the catheter of organisms post procedure. Though flushing might help with organisms, CBI primarily focuses on preventing clots from obstructing urine flow, which is the priority here.
D: Need for increased fluid intake. Increased fluid intake may support general urinary health, but CBI's primary goal is to manage bleeding complications and maintain catheter patency after the procedure.
Question 7
Multiple Choice
A nurse is caring for a patient who has a urinary diversion (urostomy) after cystectomy (removal of the bladder) to treat bladder cancer. What interventions are indicated for this patient?
Correct!
Incorrect
The correct answer is: A,C,F
Rationale
Measuring the patient's fluid intake and output, emptying the appliance frequently, and monitoring the return of intestinal function and peristalsis are essential interventions for effective urostomy care and patient health.
B: Keeping the skin around the stoma moist. Skin around the stoma should be kept dry to prevent irritation and maintain skin integrity, which is critical for patient comfort and health.
D: Reporting any mucus in the urine to the primary care provider. While mucus can occur, it is generally a normal finding in urostomy patients and does not necessarily require immediate reporting unless accompanied by other concerning symptoms.
E: Encouraging the patient to look away when changing the appliance. Patients should be encouraged to engage with their care routine for education and comfort, rather than avoiding the process, which may increase anxiety.
Correct Answer: A,C,F
Rationale: Measuring the patient's fluid intake and output, emptying the appliance frequently, and monitoring the return of intestinal function and peristalsis are essential interventions for effective urostomy care and patient health.
B: Keeping the skin around the stoma moist. Skin around the stoma should be kept dry to prevent irritation and maintain skin integrity, which is critical for patient comfort and health.
D: Reporting any mucus in the urine to the primary care provider. While mucus can occur, it is generally a normal finding in urostomy patients and does not necessarily require immediate reporting unless accompanied by other concerning symptoms.
E: Encouraging the patient to look away when changing the appliance. Patients should be encouraged to engage with their care routine for education and comfort, rather than avoiding the process, which may increase anxiety.
Question 8
Regular
A nurse is changing the stoma appliance on a patient's ileal conduit. Which finding requires the nurse to follow up with the provider?
Correct!
Incorrect
The correct answer is: D
Rationale
D: Stoma is a purple-black color.
A purple-black stoma indicates potential necrosis or compromised blood supply, requiring immediate follow-up with the provider to assess for serious complications that could threaten the patient's health.
A: Stoma is moist.
A moist stoma is a normal finding, indicating adequate hydration and healthy tissue. This observation does not signify any immediate concern or require further intervention from the provider.
B: Skin around the stoma is irritated.
While irritation can be uncomfortable, it often results from appliance friction or moisture. This condition can typically be managed with proper skin care and does not necessitate urgent provider involvement.
C: Urine is leaking from the stoma.
Urine leakage may suggest issues with the stoma appliance or positioning. However, this can often be addressed through appliance adjustment, rather than requiring immediate follow-up with the provider.
Correct Answer: D
Rationale: D: Stoma is a purple-black color.
A purple-black stoma indicates potential necrosis or compromised blood supply, requiring immediate follow-up with the provider to assess for serious complications that could threaten the patient's health.
A: Stoma is moist.
A moist stoma is a normal finding, indicating adequate hydration and healthy tissue. This observation does not signify any immediate concern or require further intervention from the provider.
B: Skin around the stoma is irritated.
While irritation can be uncomfortable, it often results from appliance friction or moisture. This condition can typically be managed with proper skin care and does not necessitate urgent provider involvement.
C: Urine is leaking from the stoma.
Urine leakage may suggest issues with the stoma appliance or positioning. However, this can often be addressed through appliance adjustment, rather than requiring immediate follow-up with the provider.
Question 9
Regular
A postoperative patient is having difficulty voiding and reports suprapubic pressure. What action can the nurse take to promote voiding?
Correct!
Incorrect
The correct answer is: B
Rationale
B: Assessing bladder residual using the bladder scanner. This action accurately determines the volume of urine in the bladder, helping to identify urinary retention or the need for further intervention to promote voiding effectively.
A: Pouring cold water over the patient's fingers and perineum. While this method may stimulate a reflex to void, it lacks the precision needed to assess underlying urinary retention issues.
C: Immediately encouraging the patient to void. This approach may pressure the patient without addressing potential anatomical or physiological factors that contribute to the inability to void effectively.
D: Recommending an indwelling catheter. This option bypasses the opportunity for the patient to void naturally and introduces risks such as infection, making it less favorable in this scenario.
Correct Answer: B
Rationale: B: Assessing bladder residual using the bladder scanner. This action accurately determines the volume of urine in the bladder, helping to identify urinary retention or the need for further intervention to promote voiding effectively.
A: Pouring cold water over the patient's fingers and perineum. While this method may stimulate a reflex to void, it lacks the precision needed to assess underlying urinary retention issues.
C: Immediately encouraging the patient to void. This approach may pressure the patient without addressing potential anatomical or physiological factors that contribute to the inability to void effectively.
D: Recommending an indwelling catheter. This option bypasses the opportunity for the patient to void naturally and introduces risks such as infection, making it less favorable in this scenario.
Question 10
Regular
A nurse caring for a patient who just began hemodialysis assesses the patient's AV fistula. Nursing documentation includes: '5/10/25 0930 AV fistula in the right forearm negative for thrill and bruit. Patient denies pain and tenderness.' Which finding is essential for the nurse report to the health care provider?
Correct!
Incorrect
The correct answer is: A
Rationale
Thrill and bruit are absent.
The absence of thrill and bruit in an AV fistula is critical as these findings indicate compromised blood flow, which can lead to complications. Continuous assessment is vital to ensure the fistula remains patent and functional for hemodialysis, making this finding essential for timely intervention and management by the healthcare provider.
B: Area is without redness or swelling. While this finding suggests no infection, it does not directly indicate the functional status of the AV fistula.
C: Patient denies pain and tenderness. Absence of pain and tenderness provides reassurance but does not address the vital vascular assessment needed for the AV fistula's functionality.
D: Trace edema of the fingers is present. Trace edema may suggest fluid overload or other issues but is less critical than assessing the patency and functionality of the AV fistula itself.
Correct Answer: A
Rationale: Thrill and bruit are absent.
The absence of thrill and bruit in an AV fistula is critical as these findings indicate compromised blood flow, which can lead to complications. Continuous assessment is vital to ensure the fistula remains patent and functional for hemodialysis, making this finding essential for timely intervention and management by the healthcare provider.
B: Area is without redness or swelling. While this finding suggests no infection, it does not directly indicate the functional status of the AV fistula.
C: Patient denies pain and tenderness. Absence of pain and tenderness provides reassurance but does not address the vital vascular assessment needed for the AV fistula's functionality.
D: Trace edema of the fingers is present. Trace edema may suggest fluid overload or other issues but is less critical than assessing the patency and functionality of the AV fistula itself.
Question 11
Regular
A nurse is caring for an alert, ambulatory, older adult with urinary frequency who has difficulty making it to the bathroom in time. Which nursing intervention is most appropriate to include in the care plan for this patient?
Correct!
Incorrect
The correct answer is: C
Rationale
Teaching the patient how to perform PFMT exercises at regular intervals is the most appropriate intervention. These exercises strengthen pelvic floor muscles, enhancing bladder control and reducing urinary frequency, thus promoting independence and dignity for the older adult.
A: Explaining that incontinence is an expected occurrence with aging undermines the potential for treatment and fails to empower the patient. It does not address the actual issue of urinary frequency.
B: Asking the patient's family/caregivers to purchase incontinence pads for the patient merely provides a temporary solution. It does not encourage the patient to actively engage in managing their urinary issues.
D: Inserting an indwelling catheter to prevent skin breakdown introduces unnecessary risk of infection and complications. It is an invasive measure that does not promote the patient's autonomy or comfort.
Correct Answer: C
Rationale: Teaching the patient how to perform PFMT exercises at regular intervals is the most appropriate intervention. These exercises strengthen pelvic floor muscles, enhancing bladder control and reducing urinary frequency, thus promoting independence and dignity for the older adult.
A: Explaining that incontinence is an expected occurrence with aging undermines the potential for treatment and fails to empower the patient. It does not address the actual issue of urinary frequency.
B: Asking the patient's family/caregivers to purchase incontinence pads for the patient merely provides a temporary solution. It does not encourage the patient to actively engage in managing their urinary issues.
D: Inserting an indwelling catheter to prevent skin breakdown introduces unnecessary risk of infection and complications. It is an invasive measure that does not promote the patient's autonomy or comfort.
Question 12
Regular
A nurse is caring for a patient who is taking phenazopyridine (a urinary tract analgesic) for a UTI. The patient states, 'My urine was bright orange-red today; I think I'm bleeding. Something is terribly wrong.' How will the nurse best respond?
Correct!
Incorrect
The correct answer is: A
Rationale
The medication causes a red-orange tinge to the urine; it is expected. This response reassures the patient that their observation is a known side effect of phenazopyridine, alleviating anxiety while maintaining a clear focus on the medication's characteristics.
B: I will test your urine for blood. This approach may induce unnecessary worry and does not address the known side effect of the medication, potentially escalating the patient's anxiety.
C: This may be the result of an injury to your bladder. This statement introduces an alarming possibility that lacks foundation, diverting attention from the benign explanation provided by the medication's effects.
D: I'll hold the medication and let the provider know you are allergic to the drug. Suggesting an allergy without evidence leads to inappropriate action, as the bright color is a common and harmless outcome of the medication.
Correct Answer: A
Rationale: The medication causes a red-orange tinge to the urine; it is expected. This response reassures the patient that their observation is a known side effect of phenazopyridine, alleviating anxiety while maintaining a clear focus on the medication's characteristics.
B: I will test your urine for blood. This approach may induce unnecessary worry and does not address the known side effect of the medication, potentially escalating the patient's anxiety.
C: This may be the result of an injury to your bladder. This statement introduces an alarming possibility that lacks foundation, diverting attention from the benign explanation provided by the medication's effects.
D: I'll hold the medication and let the provider know you are allergic to the drug. Suggesting an allergy without evidence leads to inappropriate action, as the bright color is a common and harmless outcome of the medication.
Question 13
Multiple Choice
A nurse is caring for a male patient who had a urinary sheath applied following hip surgery. What nursing interventions are appropriate to include when caring for this patient?
Correct!
Incorrect
The correct answer is: A,E,F
Rationale
Preventing the tubing from kinking to maintain free urinary drainage is essential for ensuring that urine flows unobstructed, reducing the risk of complications such as urinary retention or infection. Additionally, leaving 1 to 2 inches (2.5 to 5 cm) beyond the tip of the penis prevents irritation and allows for proper fit, while ensuring the device does not restrict blood flow maintains patient comfort and safety.
B: Changing the sheath weekly and provide hygiene does not address the immediate need for continuous care and monitoring required post-surgery, which is critical for preventing urinary complications.
C: Fastening the sheath tightly to prevent the possibility of leakage can cause discomfort and restrict blood circulation, leading to potential tissue damage and other complications rather than ensuring proper function.
D: Having the patient maintain bedrest to prevent the sheath from slipping off limits mobility unnecessarily and does not consider the importance of regular monitoring and adjustments to the urinary sheath.
Correct Answer: A,E,F
Rationale: Preventing the tubing from kinking to maintain free urinary drainage is essential for ensuring that urine flows unobstructed, reducing the risk of complications such as urinary retention or infection. Additionally, leaving 1 to 2 inches (2.5 to 5 cm) beyond the tip of the penis prevents irritation and allows for proper fit, while ensuring the device does not restrict blood flow maintains patient comfort and safety.
B: Changing the sheath weekly and provide hygiene does not address the immediate need for continuous care and monitoring required post-surgery, which is critical for preventing urinary complications.
C: Fastening the sheath tightly to prevent the possibility of leakage can cause discomfort and restrict blood circulation, leading to potential tissue damage and other complications rather than ensuring proper function.
D: Having the patient maintain bedrest to prevent the sheath from slipping off limits mobility unnecessarily and does not consider the importance of regular monitoring and adjustments to the urinary sheath.
Question 14
Regular
A nurse receives a prescription to catheterize a patient following surgery. What nursing action reflects correct technique?
Correct!
Incorrect
The correct answer is: B
Rationale
Selecting the smallest appropriate size indwelling urinary catheter ensures comfort and minimizes trauma to the urethra during catheterization, which is essential for optimal patient care and recovery after surgery.
A: Planning to use different equipment for catheterization of male versus female patients does not address the immediate need for size selection, which is crucial for patient safety and comfort.
C: Sterilizing the equipment prior to insertion, while important for infection control, does not focus on the size of the catheter, which directly affects patient experience.
D: Avoiding filling the balloon with sterile water to prevent pressure on tissues contradicts safe practice; proper inflation is necessary to secure the catheter and prevent complications.
Correct Answer: B
Rationale: Selecting the smallest appropriate size indwelling urinary catheter ensures comfort and minimizes trauma to the urethra during catheterization, which is essential for optimal patient care and recovery after surgery.
A: Planning to use different equipment for catheterization of male versus female patients does not address the immediate need for size selection, which is crucial for patient safety and comfort.
C: Sterilizing the equipment prior to insertion, while important for infection control, does not focus on the size of the catheter, which directly affects patient experience.
D: Avoiding filling the balloon with sterile water to prevent pressure on tissues contradicts safe practice; proper inflation is necessary to secure the catheter and prevent complications.
Question 15
Multiple Choice
A nurse in the emergency room is teaching a patient how to collect a midstream urine specimen. What instructions will the nurse give the patient?
Correct!
Incorrect
The correct answer is: A,C,D
Rationale
A: Wash your hands with soap and water. Proper hand hygiene is crucial before collecting a midstream urine specimen to prevent contamination, ensuring the accuracy of the test results and promoting patient safety.
B: Open the container and place the lid face down on the counter. This practice risks contamination of the sterile container's inner surface, potentially compromising sample integrity.
E: Lean the collection container against the urinary opening and void into the container. This method may increase chances of contamination, as it does not follow the recommended midstream collection technique.
F: Void an ounce, then remove the container and finish voiding in the toilet. This approach does not emphasize the importance of collecting the midstream portion, which is essential for accurate urine analysis.
Correct Answer: A,C,D
Rationale: A: Wash your hands with soap and water. Proper hand hygiene is crucial before collecting a midstream urine specimen to prevent contamination, ensuring the accuracy of the test results and promoting patient safety.
B: Open the container and place the lid face down on the counter. This practice risks contamination of the sterile container's inner surface, potentially compromising sample integrity.
E: Lean the collection container against the urinary opening and void into the container. This method may increase chances of contamination, as it does not follow the recommended midstream collection technique.
F: Void an ounce, then remove the container and finish voiding in the toilet. This approach does not emphasize the importance of collecting the midstream portion, which is essential for accurate urine analysis.
Question 16
Regular
A nurse on a pediatric surgical unit notes a 10-year-old child has developed nocturnal enuresis. What health concern will the nurse plan for?
Correct!
Incorrect
The correct answer is: B
Rationale
Nocturnal enuresis in a 10-year-old signifies a health concern related to bedwetting, especially since it occurs after the typical age of toilet training. This condition may require further assessment to identify underlying causes and potential interventions.
A: Constipation may lead to urinary issues but does not directly relate to bedwetting specifically in this age group.
C: Patient who is manipulative suggests behavioral issues rather than a medical condition, which does not apply to nocturnal enuresis.
D: Infection pertains to other urinary symptoms and is not the primary concern when assessing nocturnal enuresis in a child of this age.
Correct Answer: B
Rationale: Nocturnal enuresis in a 10-year-old signifies a health concern related to bedwetting, especially since it occurs after the typical age of toilet training. This condition may require further assessment to identify underlying causes and potential interventions.
A: Constipation may lead to urinary issues but does not directly relate to bedwetting specifically in this age group.
C: Patient who is manipulative suggests behavioral issues rather than a medical condition, which does not apply to nocturnal enuresis.
D: Infection pertains to other urinary symptoms and is not the primary concern when assessing nocturnal enuresis in a child of this age.
Question 17
Regular
A nursing student hears in report that their patient is receiving a nephrotoxic medication. The student plans care to include what action?
Correct!
Incorrect
The correct answer is: B
Rationale
Assessing for kidney damage. Monitoring renal function is crucial when administering nephrotoxic medications, as these drugs can lead to significant harm to the kidneys, resulting in acute or chronic kidney injury.
A: Teaching the patient to expect increased voiding. While increased urination can occur, it does not directly address the potential for kidney injury, which requires more focused assessment and monitoring.
C: Preventing urinary incontinence. This action does not relate to the nephrotoxic effects of the medication and fails to prioritize the critical assessment of kidney function during treatment.
D: Observing for nocturia. Although nocturia may occur, it is not a primary concern when managing the risks associated with nephrotoxic medications, which necessitate a focus on kidney damage assessment.
Correct Answer: B
Rationale: Assessing for kidney damage. Monitoring renal function is crucial when administering nephrotoxic medications, as these drugs can lead to significant harm to the kidneys, resulting in acute or chronic kidney injury.
A: Teaching the patient to expect increased voiding. While increased urination can occur, it does not directly address the potential for kidney injury, which requires more focused assessment and monitoring.
C: Preventing urinary incontinence. This action does not relate to the nephrotoxic effects of the medication and fails to prioritize the critical assessment of kidney function during treatment.
D: Observing for nocturia. Although nocturia may occur, it is not a primary concern when managing the risks associated with nephrotoxic medications, which necessitate a focus on kidney damage assessment.