- After an unimmunized individual is exposed to hepatitis B through a needle-stick injury, which
actions will the nurse plan to take (select all that apply)?
a. Administer hepatitis B vaccine.
b. Test for antibodies to hepatitis B.
c. Teach about -interferon therapy.
d. Give hepatitis B immune globulin.
e. Teach about choices for oral antiviral therapy.
ANS: A, B, D
The recommendations for hepatitis B exposure include both vaccination and immune globulin
administration. In addition, baseline testing for hepatitis B antibodies will be needed. Interferon
and oral antivirals are not used for hepatitis B prophylaxis. - It is most important that the nurse ask a patient admitted with acute glomerulonephritis about
a. history of kidney stones.
b
.
Recent sore throat and fever.
c. history of high blood pressure.
d
.
frequency of bladder infections.
ANS: B
Acute glomerulonephritis frequently occurs after a streptococcal infection such as strep throat. It
is not caused by kidney stones, hypertension, or urinary tract infection (UTI). - Which finding for a patient admitted with glomerulonephritis indicates to the nurse that treatment
has been effective?
a. The patient denies pain with voiding.
b. The urine dipstick is negative for nitrites.
c. The antistreptolysin-O (ASO) titer is decreased.
d. The periorbital and peripheral edema is resolved.
ANS: D
Because edema is a common clinical manifestation of glomerulonephritis, resolution of the
edema indicates that the prescribed therapies have been effective. Nitrites will be negative and
the patient will not experience dysuria because the patient does not have a urinary tract infection.
Antibodies to streptococcus will persist after a streptococcal infection.
10.To preventrecurrence of uric acid renal calculi, the nurse teaches the patient to avoid eating
a. milk and cheese.
b. Sardines and liver.
c. legumes and dried fruit.
d. spinach, chocolate, and tea.
ANS: B
Organ meats and fish such as sardines increase purine levels and uric acid. Spinach, chocolate, and
tomatoes should be avoided in patients who have oxalate stones. Milk, dairy products, legumes, and
dried fruits may increase the incidence of calcium-containing stones. - The nurse teaches a 64-year-old woman to prevent the recurrence of renal calculi by
a. using a filter to strain all urine.
b. avoiding dietary sources of calcium.
c. choosing diuretic fluids such as coffee.
d. drinking 2000 to 3000 mL of fluid a day.
ANS: D
A fluid intake of 2000 to 3000 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. - A 55-year-old woman admitted for shoulder surgery asks the nurse for a perineal pad, stating
that laughing or coughing causes leakage of urine.Which intervention is most appropriate to
include in the care plan?
a. Assist the patient to the bathroom q3hr.
b. Place a commode at the patient’s bedside.
c. Demonstrate how to perform the Credé maneuver.
d. Teach the patient how to perform Kegel exercises.
ANS: D
Kegel exercises to strengthen the pelvic floor muscles will help reduce stress incontinence. The Credé
maneuver is used to help empty the bladder for patients with overflow incontinence. Placing the commode
close to the bedside and assisting the patient to the bathroom are helpful for functional incontinence. - A patient admitted to the hospital with pneumonia has a history of functional urinary
incontinence. Which nursing action will be included in the plan of care?
a. Demonstrate the use of the Credé maneuver.
b. Teach exercises to strengthen the pelvic floor.
c. Place a bedside commode close to the patient’s bed.
d. Use an ultrasound scanner to check postvoiding residuals.
ANS: C
Modifications in the environment make it easier to avoid functional incontinence. Checking for residual
urine and performing the Credé maneuver are interventions for overflow incontinence. Kegel exercises
are useful for stress incontinence. - A patient who had surgery for creation of an ileal conduit 3 days ago will not look at the stoma and
requests that only the ostomy nurse specialist does the stoma care. The nurse identifies a nursing diagnosis of
a. anxiety related to effects of procedure on lifestyle.
b. Disturbed body image related to change in function.
c. readiness for enhanced coping related to need for information.
d. self-care deficit, toileting, related to denial of altered body function.
ANS: B
The patient’s unwillingness to look at the stoma or participate in care indicates that disturbed body image
is the best diagnosis. No data suggest that the impact on lifestyle is a concern for the patient. The patient
does not appear to be ready for enhanced coping. The patient’s insistence that only the ostomy nurse care
for the stoma indicates that denial is not present. - A 76-year-old with benign prostatic hyperplasia (BPH) is agitated and confused, with a markedly distended
bladder. Which intervention prescribed by the health care provider should the nurse implement first?
a. Insert a urinary retention catheter.
b. Schedule an intravenous pyelogram (IVP).
c. Draw blood for a serum creatinine level.
d. Administer lorazepam (Ativan) 0.5 mg PO.
ANS: A
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. - Which nursing action is of highest priority for a 68-year-old patient with renal calculi who
is being admitted to the hospital with gross hematuria and severe colicky left flank pain?
a. Administer prescribed analgesics.
b. Monitor temperature every 4 hours.
c. Encourage increased oral fluid intake.
d. Give antiemetics as needed for nausea.
ANS: A
Although all of the nursing actions may be used for patients with renal lithiasis, the patient’s presentation
indicates that management of pain is the highest priority action. If the patient has urinary obstruction,
increasing oral fluids may increase the symptoms. There is no evidence of infection or nausea. - The nurse is caring for a patient who has had an ileal conduitfor several years. Which nursing action
could be delegated to unlicensed assistive personnel (UAP)?
a. Change the ostomy appliance.
b
.
Choose the appropriate ostomy bag.
c. Monitor the appearance of the stoma.
d
.
Assess for possible urinary tract infection (UTI).
ANS: A
Changing the ostomy appliance for a stable patient could be done by UAP. Assessments of the site, choosing
the appropriate ostomy bag, and assessing for (UTI) symptoms require more education and scope of practice
and should be done by the registered nurse (RN). - A 32-year-old 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?
a. Infuse 5% dextrose in normal saline at 75 mL/hr.
b. Order regular diet after patient is awake and alert.
c. Give ketorolac (Toradol) 10 mg PO PRN for pain.
d. Draw blood urea nitrogen (BUN) and creatinine in 2 hours.
ANS: C
The nonsteroidal anti-inflammatory drugs (NSAIDs) should be avoided in patients with decreased renal
function because nephrotoxicity is a potentia l adverse effect. The other orders do not need any
clarification or change. - A patient has been diagnosed with urinary tract calculi that are high in uric acid. Which foods
will the nurse teach the patient to avoid (select all that apply)?
a. Milk
b. Liver
c. Spinach
d. Chicken
e. Cabbage
f. Chocolate
ANS: B, D
Meats contain purines, which are metabolized to uric acid. The other foods might be restricted in
patients who have calcium or oxalate stones. - A patient who has acute glomerulonephritis is hospitalized with hyperkalemia. Which
information will the nurse monitor to evaluate the effectiveness of the prescribed calcium
gluconate IV?
a. Urine volume
b. Calcium level
c. Cardiac rhythm
d. Neurologic status
ANS: C
The calcium gluconate helps prevent dysrhythmias that might be caused by the hyperkalemia. The nurse
will monitor the other data as well, but these will not be helpful in determining the effectiveness of the
calcium gluconate. - A patient will need vascular access for hemodialysis. Which statement by the nurse accurately
describes an advantage of a fistula over a graft?
a. A fistula is much less likely to clot.
b. A fistula increases patient mobility.
c. A fistula can accommodate larger needles.
d. A fistula can be used sooner after surgery.
ANS: A
Arteriovenous (AV) fistulas are much less likely to clot than grafts, although it takes longer for
them to mature to the point where they can be used for dialysis. The choice of an AV fistula or a
graft does not have an impact on needle size or patient mobility. - When caring for a patient with a left arm arteriovenous fistula, which action will the nurse
include in the plan of care to maintain the patency of the fistula?
a. Auscultate for a bruit at the fistula site.
b. Assess the quality of the left radial pulse.
c. Compare blood pressures in the left and right arms.
d. Irrigate the fistula site with saline every 8 to 12 hours.
ANS: A
The presence of a thrill and bruit indicates adequate blood flow through the fistula. Pulse rate and quality
are not good indicators of fistula patency. Blood pressures should never be obtained on the arm with a
fistula. Irrigation of the fistula might damage the fistula, and typically only dialysis staff would access the
fistula.
25.A 72-year-old patient with a history of benign prostatic hyperplasia (BPH) is admitted with
acute urinary retention and elevated blood urea nitrogen (BUN) and creatinine levels. Which
prescribed therapy should the nurse implement first?
a. Insert urethral catheter.
b. Obtain renal ultrasound.
c. Draw a complete blood count.
d. Infuse normal saline at 50 mL/hour.
ANS: A
The patient’s elevation in BUN is most likely associated with hydronephrosis caused by the acute
urinary retention, so the insertion of a retention catheter is the first action to prevent ongoing
postrenal failure for this patient. The other actions also are appropriate, but should be
implemented after the retention catheter. - Which laboratory value should the nurse review to determine whether a patient’s
hypothyroidism is caused by a problem with the anteriorpituitary gland or with the thyroid
gland?
a. Thyroxine (T4) level
b. Triiodothyronine (T3) level
c. Thyroid-stimulating hormone (TSH) level
d. Thyrotropin-releasing hormone (TRH) level
ANS: C
A low TSH level indicates that the patient’s hypothyroidism is caused by decreased anterior
pituitary secretion of TSH. Low T3 and T4 levels are not diagnostic of the primary cause of the
hypothyroidism. TRH levels indicate the function of the hypothalamus. - Which action by a new registered nurse (RN) caring for a patient with a goiter and
possible hyperthyroidism indicates that the charge nurse needs to do more teaching?
a. The RN checks the blood pressure on both arms.
b. The RN palpates the neck thoroughly to check thyroid size.
c. The RN lowers the thermostat to decrease the temperature in the room.
d. The RN orders nonmedicated eye drops to lubricate the patient’s bulging eyes.
ANS: B
Palpation can cause the release of thyroid hormones in a patient with an enlarged thyroid and
should be avoided. The other actions by the new RN are appropriate when caring for a patient
with an enlarged thyroid. - A 27-year-old patient admitted with diabetic ketoacidosis (DKA) has a serum glucose
level of 732 mg/dL and serum potassium level of 3.1 mEq/L. Which action prescribed by the
health care provider should the nurse take first?
a. Place the patient on a cardiac monitor.
b. Administer IV potassium supplements.
c. Obtain urine glucose and ketone levels.
d. Start an insulin infusion at 0.1 units/kg/hr.
ANS: A
Hypokalemia can lead to potentially fatal dysrhythmias such as ventricular tachycardia and
ventricular fibrillation, which would be detected with electrocardiogram (ECG) monitoring.
Because potassium must be infused over at least 1 hour, the nurse should initiate cardiac
monitoring before infusion of potassium. Insulin should not be administered without cardiac
monitoring because insulin infusion will further decrease potassium levels. Urine glucose and
ketone levels are not urgently needed to manage the patient’s care. - A patient who was admitted with diabetic ketoacidosis secondary to a urinary tract
infection has been weaned off an insulin drip 30 minutes ago. The patient reports feeling
lightheaded and sweaty. Which action should the nurse take first?
a. Infuse dextrose 50% by slow IV push.
b. Administer 1 mg glucagon subcutaneously.
c. Obtain a glucose reading using a finger stick.
d. Have the patient drink 4 ounces of orange juice.
ANS: C
The patient’s clinical manifestations are consistent with hypoglycemia and the initial action
should be to check the patient’s glucose with a finger stick or order a stat blood glucose. If the
glucose is low, the patient should ingest a rapid-acting carbohydrate, such as orange juice.
Glucagon or dextrose 50% might be given if the patient’s symptoms become worse or if the
patient is unconscious. - An expected nursing diagnosis for a 30-year-old patient admitted to the hospital with
symptoms of diabetes insipidus is
a. excess fluid volume related to intake greater than output.
b. impaired gas exchange related to fluid retention in lungs.
c. sleep pattern disturbance related to frequent waking to void.
d. risk for impaired skin integrity related to generalized edema.
ANS: C
Nocturia occurs as a result of the polyuria caused by diabetes insipidus. Edema, excess fluid
volume, and fluid retention are not expected. - A 62-year-old patient with hyperthyroidism is to be treated with radioactive iodine (RAI).
The nurse instructs the patient
a. about radioactive precautions to take with all body secretions.
b. that symptoms of hyperthyroidism should be relieved in about a week.
c. that symptoms of hypothyroidism may occur as the RAI therapy takes effect.
d. to discontinue the antithyroid medications taken before the radioactive therapy.
ANS: C
There is a high incidence of postradiation hypothyroidism after RAI, and the patient should be
monitored for symptoms of hypothyroidism. RAI has a delayed response, with the maximum
effect not seen for 2 to 3 months, and the patient will continue to take antithyroid medications
during this time. The therapeutic dose of radioactive iodine is low enough that no radiation safety
precautions are needed. - An 82-year-old patient in a long-term care facility has several medications prescribed.
After the patient is newly diagnosed with hypothyroidism, the nurse will need to consult with the
health care provider before administering
a. docusate (Colace).
b. ibuprofen (Motrin).
c. diazepam (Valium).
d. cefoxitin (Mefoxin).
ANS: C
Worsening of mental status and myxedema coma can be precipitated by the use of sedatives,
especially in older adults. The nurse should discuss the use of diazepam with the health care
provider before administration. The other medications may be given safely to the patient. - Which finding for a patient who has hypothyroidism and hypertension indicates that the
nurse should contact the health care provider before administering levothyroxine (Synthroid)?
a. Increased thyroxine (T4) level
b. Blood pressure 112/62 mm Hg
c. Distant and difficult to hear heart sounds
d. Elevated thyroid stimulating hormone level
ANS: A
An increased thyroxine level indicates the levothyroxine dose needs to be decreased. The other
data are consistent with hypothyroidism and the nurse should administer the levothyroxine. - A 38-year-old male patient is admitted to the hospital in Addisonian crisis. Which patient
statement supports a nursing diagnosis of ineffective self-health management related to lack of
knowledge about management of Addison’s disease?
a. “I frequently eat at restaurants, and my food has a lot of added salt.”
b. “I had the stomach flu earlier this week, so I couldn’t take the hydrocortisone.”
c. “I always double my dose of hydrocortisone on the days that I go for a long run.”
d. “I take twice as much hydrocortisone in the morning dose as I do in the afternoon.”
ANS: B
The need for hydrocortisone replacement is increased with stressors such as illness, and the
patient needs to be taught to call the health care provider because medication and IV fluids and
electrolytes may need to be given. The other patient statements indicate appropriate management
of the Addison’s disease. - A 56-year-old female patient has an adrenocortical adenoma, causing
hyperaldosteronism. The nurse providing care should
a. monitor the blood pressure every 4 hours.
b. elevate the patient’s legs to relieve edema.
c. monitor blood glucose level every 4 hours.
d. order the patient a potassium-restricted diet.
ANS: A
Hypertension caused by sodium retention is a common complication of hyperaldosteronism.
Hyperaldosteronism does not cause an elevation in blood glucose. The patient will be
hypokalemic and require potassium supplementation before surgery. Edema does not usually
occur with hyperaldosteronism. - The nurse is caring for a patient admitted with diabetes insipidus (DI). Which information
is most important to report to the health care provider?
a. The patient is confused and lethargic.
b. The patient reports a recent head injury.
c. The patient has a urine output of 400 mL/hr.
d. The patient’s urine specific gravity is 1.003.
ANS: A
The patient’s confusion and lethargy may indicate hypernatremia and should be addressed
quickly. In addition, patients with DI compensate for fluid losses by drinking copious amounts of
fluids, but a patient who is lethargic will be unable to drink enough fluids and will become
hypovolemic. A high urine output, low urine specific gravity, and history of a recent head injury
are consistent with diabetes insipidus, but they do not require immediate nursing action to avoid
life-threatening complications. - A 23-year-old patient is admitted with diabetes insipidus. Which action will be most
appropriate for the registered nurse (RN) to delegate to an experienced licensed
practical/vocational nurse (LPN/LVN)?
a. Titrate the infusion of 5% dextrose in water.
b. Teach the patient how to use desmopressin (DDAVP) nasal spray.
c. Assess the patient’s hydration status every 8 hours.
d. Administer subcutaneous DDAVP.
ANS: D
Administration of medications is included in LPN/LVN education and scope of practice.
Assessments, patient teaching, and titrating fluid infusions are more complex skills and should
be done by the RN. - Which question should the nurse ask when assessing a 60-year-old patient who has a
history of benign prostatic hyperplasia (BPH)?
a. “Have you noticed any unusual discharge from your penis?”
b. “Has there been any change in your sex life in the last year?”
c. “Has there been a decrease in the force of your urinary stream?”
d. “Have you been experiencing any difficulty in achieving an erection?”
ANS: C
Enlargement of the prostate blocks the urethra, leading to urinary changes such as a decrease in
the force of the urinary stream. The other questions address possible problems with infection or
sexual difficulties, but they would not be helpful in determining whether there were functional
changes caused by BPH. - The nurse will plan to teach a 51-year-old man who is scheduled for an annual physical
exam about a(n)
a. increased risk for testicular cancer.
b. possible changes in erectile function.
c. normal decreases in testosterone level.
d. prostate specific antigen (PSA) testing.
ANS: D
PSA testing may be recommended annually for men, starting at age 50. There is no indication
that the other patient teaching topics are appropriate for this patient. - The nurse teaching a young women’s community service group about breast selfexamination (BSE) will include that
a. BSE will reduce the risk of dying from breast cancer.
b. BSE should be done daily while taking a bath or shower.
c. annual mammograms should be scheduled in addition to BSE.
d. performing BSE after the menstrual period is more comfortable.
ANS: D
Performing BSE at the end of the menstrual period will reduce the breast tenderness associated
with the procedure. The evidence is not clear that BSE reduces mortality from breast cancer. BSE
should be done monthly. Annual mammograms are not routinely scheduled for women under age
40, and newer guidelines suggest delaying them until age 50. - After a 48-year-old patient has had a modified radical mastectomy, the pathology report
identifies the tumor as an estrogen-receptor positive adenocarcinoma. The nurse will plan to
teach the patient about
a. estradiol (Estrace).
b. raloxifene (Evista).
c. tamoxifen (Nolvadex).
d. trastuzumab (Herceptin).
ANS: C
Tamoxifen is used for estrogen-dependent breast tumors in premenopausal women. Raloxifene is
used to prevent breast cancer, but it is not used postmastectomy to treat breast cancer. Estradiol
will increase the growth of estrogen-dependent tumors. Trastuzumab is used to treat tumors that
have the HER-2 receptor. - The nurse provides discharge teaching for a 61-year-old patient who has had a left
modified radical mastectomy and lymph node dissection. Which statement by the patient
indicates that teaching has been successful?
a. “I will need to use my right arm and to rest the left one.”
b. “I will avoid reaching over the stove with my left hand.”
c. “I will keep my left arm in a sling until the incision is healed.”
d. “I will stop the left arm exercises if moving the arm is painful.”
ANS: B
The patient should avoid any activity that might injure the left arm, such as reaching over a
burner. If the left arm exercises are painful, analgesics should be used and the exercises
continued in order to restore strength and range of motion. The left arm should be elevated at or
above heart level and should be used to improve range of motion and function. - A patient newly diagnosed with stage I breast cancer is discussing treatment options with
the nurse. Which statement by the patient indicates that additional teaching may be needed?
a. “There are several options that I can consider for treating the cancer.”
b. “I will probably need radiation to the breast after having the surgery.”
c. “Mastectomy is the best choice to decrease the chance of cancer recurrence.”
d. “I can probably have reconstructive surgery at the same time as a mastectomy.”
ANS: C
The survival rates with lumpectomy and radiation or modified radical mastectomy are
comparable. The other patient statements indicate a good understanding of stage I breast cancer
treatment. - When the nurse is working in the women’s health care clinic, which action is appropriate
to take?
a. Teach a healthy 30-year-old about the need for an annual mammogram.
b. Discuss scheduling an annual clinical breast examination with a 22-year-old.
c. Explain to a 60-year-old that mammography frequency can be reduced to every 3 years.
d. Teach a 28-year-old with a BRCA-1 mutation about magnetic resonance imaging (MRI).
ANS: D
MRI (in addition to mammography) is recommended for women who are at high risk for breast
cancer. A young woman should have a clinical breast exam every 3 years. Annual mammograms
are recommended for women over 50. - When using the accompanying illustration to teach a patient about breast selfexamination, the nurse will include the information that most breast cancers are located in which
part of the breast?
a. 1
b. 2
c. 3
d. 4
e. 5
ANS: A
The upper outer quadrant is the location of most of the glandular tissue of the breast. - A 32-year-old patient has oral contraceptives prescribed for endometriosis. The nurse will
teach the patient to
a. expect to experience side effects such as facial hair.
b. take the medication every day for the next 9 months.
c. take calcium supplements to prevent developing osteoporosis during therapy.
d. use a second method of contraception to ensure that she will not become pregnant.
ANS: B
When oral contraceptives are prescribed to treat endometriosis, the patient should take the
medications continuously for 9 months. Facial hair is a side effect of synthetic androgens. The
patient does not need to use additional contraceptive methods. The hormones in oral
contraceptives will protect against osteoporosis. - A 28-year-old patient with endometriosis asks why she is being treated with
medroxyprogesterone (Depo-Provera), a medication that she thought was an oral contraceptive.
The nurse explains that this therapy
a. suppresses the menstrual cycle by mimicking pregnancy.
b. will relieve symptoms such as vaginal atrophy and hot flashes.
c. prevents a pregnancy that could worsen the menstrual bleeding.
d. will lead to permanent suppression of abnormal endometrial tissues.
ANS: A
Depo-Provera induces a pseudopregnancy, which suppresses ovulation and causes shrinkage of
endometrial tissue. Menstrual bleeding does not occur during pregnancy. Vaginal atrophy and hot
flashes are caused by synthetic androgens such as danazol or gonadotropin-releasing hormone
agonists (GNRH) such as leuprolide. Although hormonal therapies will control endometriosis
while the therapy is used, endometriosis will recur once the menstrual cycle is reestablished. - A nursing diagnosis that is likely to be appropriate for a 67-year-old woman who has just
been diagnosed with stage III ovarian cancer is
a. sexual dysfunction related to loss of vaginal sensation.
b. risk for infection related to impaired immune function.
c. anxiety related to cancer diagnosis and need for treatment decisions.
d. situational low self-esteem related to guilt about delaying medical care.
ANS: C
The patient with stage III ovarian cancer is likely to be anxious about the poor prognosis and
about the need to make decisions about the multiple treatments that may be used. Decreased
vaginal sensation does not occur with ovarian cancer. The patient may develop immune
dysfunction when she receives chemotherapy, but she is not currently at risk. It is unlikely that
the patient has delayed seeking medical care because the symptoms of ovarian cancer are vague
and occur late in the course of the cancer. - The nurse will plan to teach a 34-year-old patient diagnosed with stage 0 cervical cancer
about
a. radiation.
b. conization.
c. chemotherapy.
d. radical hysterectomy.
ANS: B
Because the carcinoma is in situ, conization can be used for treatment. Radical hysterectomy,
chemotherapy, or radiation will not be needed.
25.A 31-year-old patient who has been diagnosed with human papillomavirus (HPV) infection
gives a health history that includes smoking tobacco, taking oral contraceptives, and having been
treated twice for vaginal candidiasis. Which topic will the nurse include in patient teaching?
a. Use of water-soluble lubricants
b. Risk factors for cervical cancer
c. Antifungal cream administration
d. Possible difficulties with conception
ANS: B
Because HPV infection and smoking are both associated with increased cervical cancer risk, the
nurse should emphasize the importance of avoiding smoking. An HPV infection does not
decrease vaginal lubrication, decrease ability to conceive, or require the use of antifungal creams. - Which information will the nurse include when teaching a patient who has developed a
small vesicovaginal fistula 2 weeks into the postpartum period?
a. Take stool softeners to prevent fecal contamination of the vagina.
b. Limit oral fluid intake to minimize the quantity of urinary drainage.
c. Change the perineal pad frequently to prevent perineal skin breakdown.
d. Call the health care provider immediately if urine drains from the vagina.
ANS: C
Because urine will leak from the bladder, the patient should plan to use perineal pads and change
them frequently. A high fluid intake is recommended to decrease the risk for urinary tract
infections. Drainage of urine from the vagina is expected with vesicovaginal fistulas. Fecal
contamination is not a concern with vesicovaginal fistulas. - The nurse in the women’s health clinic has four patients who are waiting to be seen. Which
patient should the nurse see first?
a. 22-year-old with persistent red-brown vaginal drainage 3 days after having balloon
thermotherapy
b. 42-year-old with secondary amenorrhea who says that her last menstrual cycle was
3 months ago
c. 35-year-old with heavy spotting after having a progestin-containing IUD (Mirena)
inserted a month ago
d. 19-year-old with menorrhagia who has been using superabsorbent tampons and has
fever with weakness
ANS: D
The patient’s history and clinical manifestations suggest possible toxic shock syndrome, which
will require rapid intervention. The symptoms for the other patients are consistent with their
diagnoses and do not indicate life-threatening complications. - To determine the severity of the symptoms for a 68-year-old patient with benign prostatic
hyperplasia (BPH) the nurse will ask the patient about
a. blood in the urine.
b. lower back or hip pain.
c. erectile dysfunction (ED).
d. force of the urinary stream.
ANS: D
The American Urological Association (AUA) Symptom Index for a patient with BPH asks
questions about the force and frequency of urination, nocturia, etc. Blood in the urine, ED, and
back or hip pain are not typical symptoms of BPH. - The health care provider prescribes finasteride (Proscar) for a 67-year-old patient who has
benign prostatic hyperplasia (BPH). When teaching the patient about the drug, the nurse informs
him that
a. he should change position from lying to standing slowly to avoid dizziness.
b. his interest in sexual activity may decrease while he is taking the medication.
c. improvement in the obstructive symptoms should occur within about 2 weeks.
d. he will need to monitor his blood pressure frequently to assess for hypertension.
ANS: B
A decrease in libido is a side effect of finasteride because of the androgen suppression that
occurs with the drug. Although orthostatic hypotension may occur if the patient is also taking a
medication for erectile dysfunction (ED), it should not occur with finasteride alone.
Improvement in symptoms of obstruction takes about 6 months. The medication does not cause
hypertension. - The nurse will anticipate that a 61-year-old patient who has an enlarged prostate detected by
digital rectal examination (DRE) and an elevated prostate specific antigen (PSA) level will need
teaching about
a. cystourethroscopy.
b. uroflowmetry studies.
c. magnetic resonance imaging (MRI).
d. transrectal ultrasonography (TRUS).
ANS: D
In a patient with an abnormal DRE and elevated PSA, transrectal ultrasound is used to visualize
the prostate for biopsy. Uroflowmetry studies help determine the extent of urine blockage and
treatment, but there is no indication that this is a problem for this patient. Cystoscopy may be
used before prostatectomy but will not be done until after the TRUS and biopsy. MRI is used to
determine whether prostatic cancer has metastasized but would not be ordered at this stage of the
diagnostic process. - A 53-year-old man is scheduled for an annual physical exam. The nurse will plan to teach the
patient about the purpose of
a. urinalysis collection.
b. uroflowmetry studies.
c. prostate specific antigen (PSA) testing.
d. transrectal ultrasound scanning (TRUS).
ANS: C
An annual digital rectal exam (DRE) and PSA are usually recommended starting at age 50 for
men who have an average risk for prostate cancer. Urinalysis and uroflowmetry studies are done
if patients have symptoms of urinary tract infection or changes in the urinary stream. TRUS may
be ordered if the DRE or PSA is abnormal. - A 70-year-old patient who has had a transurethral resection of the prostate (TURP) for
benign prostatic hyperplasia (BPH) is being discharged from the hospital today, The nurse
determines that additional instruction is needed when the patient says which of the following?
a. “I should call the doctor if I have incontinence at home.”
b. “I will avoid driving until I get approval from my doctor.”
c. “I will increase fiber and fluids in my diet to prevent constipation.”
d. “I should continue to schedule yearly appointments for prostate exams.”
ANS: A
Because incontinence is common for several weeks after a TURP, the patient does not need to
call the health care provider if this occurs. The other patient statements indicate that the patient
has a good understanding of post-TURP instructions. - A patient with urinary obstruction from benign prostatic hyperplasia (BPH) tells the nurse,
“My symptoms are much worse this week.” Which response by the nurse is most appropriate?
a. “Have you been taking any over-the-counter (OTC) medications recently?”
b. “I will talk to the doctor about ordering a prostate specific antigen (PSA) test.”
c. “Have you talked to the doctor about surgery such as transurethral resection of the
prostate (TURP)?”
d. “The prostate gland changes in size from day to day, and this may be making your
symptoms worse.”
ANS: A
Because the patient’s increase in symptoms has occurred abruptly, the nurse should ask about
OTC medications that might cause contraction of the smooth muscle in the prostate and worsen
obstruction. The prostate gland does not vary in size from day to day. A TURP may be needed,
but more assessment about possible reasons for the sudden symptom change is a more
appropriate first response by the nurse. PSA testing is done to differentiate BPH from prostatic
cancer. - A 71-year-old patient who has benign prostatic hyperplasia (BPH) with urinary retention
is admitted to the hospital with elevated blood urea nitrogen (BUN) and creatinine. Which
prescribed therapy should the nurse implement first?
a. Infuse normal saline at 50 mL/hr.
b. Insert a urinary retention catheter.
c. Draw blood for a complete blood count.
d. Schedule a pelvic computed tomography (CT) scan.
ANS: B
The patient data indicate that the patient may have acute kidney injury caused by the BPH. The
initial therapy will be to insert a catheter. The other actions are also appropriate, but they can be
implemented after the acute urinary retention is resolved.
Final Nursing Revision1
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