Questions 40

ATI LPN

ATI LPN TextBook-Based Test Bank

Lewis's Medical Surgical Nursing in Canada, 5th Edition

Chapter 48 Questions

Question 1 of 5

The nurse is caring for a patient following rectal surgery who voids about 50 mL of urine every 30-60 minutes. Which of the following nursing actions is best?

Correct Answer: A

Rationale: A bladder scan device can be used to check for residual urine after the patient voids. Because the patient's history and clinical manifestations are consistent with overflow incontinence, it is not appropriate to have the patient drink small amounts. Although overflow incontinence is not unusual after surgery, the nurse should intervene to correct the physiological problem, not just reassure the patient. The patient may develop reflux into the renal pelvis as well as discomfort from a full bladder if the nurse waits to address the problem for several hours.

Question 2 of 5

The nurse is caring for a patient who had a nephrectomy after having massive trauma to the kidney. Which of the following assessment findings obtained postoperatively is most important to communicate to the surgeon?

Correct Answer: C

Rationale: Because the urine output should be at least 0.5 ml/kg/hour, a 20 ml output for 2 hours indicates that the patient may have decreased renal perfusion because of bleeding, inadequate fluid intake, or obstruction at the suture site. The blood pressure requires ongoing monitoring but does not indicate inadequate perfusion at this time. The patient should cough and deep breathe, but the crackles do not indicate a need for an immediate change in therapy. The incisional pain should be addressed, but this is not as potentially life-threatening as decreased renal perfusion.

Question 3 of 5

The nurse is providing patient teaching to a patient with cystitis regarding prevention of future urinary tract infections (UTIs). Which of the following patient statements indicate that teaching has been effective?

Correct Answer: D

Rationale: Voiding every 2-4 hours is recommended to prevent UTIs. Use of vaginal sprays is discouraged. The bladder should be emptied before and after intercourse, but cleaning with soap and water is not necessary. A litre of fluids is insufficient to provide adequate urine output to decrease risk for UTI.

Question 4 of 5

The nurse is caring for a patient with benign prostatic hyperplasia (BPH) and a markedly distended bladder who is agitated and confused. Which of the following interventions prescribed by the health care provider should the nurse implement first?

Correct Answer: A

Rationale: The patient's history and clinical manifestations are consistent with acute urinary retention, and the priority action is to relieve the retention by catheterization. The BUN and creatinine measurements can be obtained after the catheter is inserted. The patient's agitation may resolve once the bladder distention is corrected, and sedative drugs should be used cautiously in older patients. The IVP is an appropriate test, but does not need to be done urgently.

Question 5 of 5

Which of the following actions should the nurse teach to a patient to help prevent the recurrence of renal calculi?

Correct Answer: D

Rationale: A fluid intake of 2000-2200 ml daily is recommended to help flush out minerals before stones can form. Avoidance of calcium is not usually recommended for patients with renal calculi. Coffee tends to increase stone recurrence. There is no need for a patient to strain all urine routinely after a stone has passed, and this will not prevent stones.

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