The nurse is caring for a client with chronic pyelonephritis. Which assessment data support the diagnosis of chronic pyelonephritis?

1. The client has fever, chills, flank pain, and dysuria.

2. The client complains of fatigue, headaches, and increased urination.

3. The client had a group B beta-hemolytic strep infection last week.

4. The client has an acute viral pneumonia infection.

2. Fatigue, headache, and polyuria as well as loss of weight, anorexia, and excessive thirst are symptoms of chronic pyelonephritis.

TEST-TAKING HINT: The key to this question is the adjective "chronic." The test taker must be aware disease processes may change over time do produce different effects.

The nurse is caring for a pregnant client diagnosed with acute pyelonephritis. Which scientific rationale supports the client being hospitalized for this condition?

1. The client must be treated aggressively to prevent maternal/fetal complications.

2. The nurse can force the client to drink fluids and avoid nausea and vomiting.

3. The client will be dehydrated and there won't be sufficient blood flow to the baby.

4. Pregnant clients historically are afraid to take the antibiotics as ordered.

1. A pregnant client diagnosed with a UTI will be admitted for aggressive IV antibiotic therapy. After symptoms subside, the client will be sent home to complete the course of treatment with oral medications.

TEST-TAKING HINT: In option "2" the nurse is "forcing" a client to do something, which should be eliminated as a possible correct answer. Option "4" is a broad generalization about "all" pregnant clients and should be discarded as a possible correct answer.

The clinic nurse is caring for a client diagnosed with chronic pyelonephritis who is prescribed trimethoprim-sulfamethoxazole (Bactrim), a sulfa antibiotic, twice a day for 90 days. Which statement is the scientific rationale for prescribing this medication?

1. The antibiotic will treat the bladder spasms that accompany a urinary tract infection.

2. If the urine cannot be made bacteria free, the Bactrim will suppress bacterial growth.

3. In three (3) months, the client should be rid of all bacteria in the urinary tract.

4. The HCP is providing the client with enough medication to treat future infections.

2. Some clients develop a chronic infection and must receive antibiotic therapy as a routine daily medication to suppress bacterial growth. The prescription will be refilled after the 90 days and continued.

TEST-TAKING HINT: The question is asking why an HCP prescribes long-term use of antibiotics for a client with a chronic infection. Antibiotics treat bacterial infections. Based on this, option "1" can be eliminated. Option "3" promises "all," which is false reassurance and can be eliminated. Option "4" describes future infections, but the client currently has an infection, so this option can be eliminated.

The elderly client is diagnosed with chronic glomerulonephritis. Which laboratory value indicates to the nurse the condition has become worse?

1. The blood urea nitrogen is 15 mg/dL.

2. The creatinine level is 1.2 mg/dL.

3. The glomerular filtration rate is 40 mL/min.

4. The 24-hour creatinine clearance is 100 mL/min.

3. Glomerular filtration rate (GFR) is approximately 120 mL/min. If the GFR is decreased to 40 mL/min, the kidneys are functioning at about one-third filtration capacity.

TEST-TAKING HINT: The nurse must memo- rize common laboratory values. BUN and creatinine levels are common laboratory values used to determine status in a number of diseases. Options "1" and "2" are normal values and could be eliminated. Then, the test taker could choose from only two (2) options.

The nurse is preparing a plan of care for the client diagnosed with acute glomerulonephritis. Which statement is an appropriate long-term goal?

1. The client will have a blood pressure within normal limits.

2. The client will show no protein in the urine.

3. The client will maintain normal renal function.

4. The client will have clear lung sounds.

3. A long-term complication of glomerulonephritis is it can become chronic if unresponsive to treatment, and this can lead to end-stage renal disease. Maintaining renal function is an appropriate long-term goal.

TEST-TAKING HINT: Answer options "1," "2," and "4" all refer to body processes controlled or treated immediately after assessment of the problem. The stem is requesting a long- term goal.

A nurse assesses a client with polycystic kidney disease (PKD). Which assessment finding should alert the nurse to immediately contact the health care provider?
a. Flank pain
b. Periorbital edema
c. Bloody and cloudy urine
d. Enlarged abdomen

ANS: B
Periorbital edema would not be a finding related to PKD and should be investigated further. Flank pain and a distended or enlarged abdomen occur in PKD because the kidneys enlarge and displace other organs. Urine can be bloody or cloudy as a result of cyst rupture or infection.

After teaching a client with early polycystic kidney disease (PKD) about nutritional therapy, the nurse assesses the client’s understanding. Which statement made by the client indicates a correct understanding of the teaching?
a. “I will take a laxative every night before going to bed.”
b. “I must increase my intake of dietary fiber and fluids.”
c. “I shall only use salt when I am cooking my own food.”
d. “I’ll eat white bread to minimize gastrointestinal gas.”

ANS: B
Clients with PKD often have constipation, which can be managed with increased fiber, exercise, and drinking plenty of water. Laxatives should be used cautiously. Clients with PKD should be on a restricted salt diet, which includes not cooking with salt. White bread has a low fiber count and would not be included in a high-fiber diet.

A nurse cares for a middle-aged female client with diabetes mellitus who is being treated for the third episode of acute pyelonephritis in the past year. The client asks, “What can I do to help prevent these infections?” How should the nurse respond?
a. “Test your urine daily for the presence of ketone bodies and proteins.”
b. “Use tampons rather than sanitary napkins during your menstrual period.”
c. “Drink more water and empty your bladder more frequently during the day.”
d. “Keep your hemoglobin A1c under 9% by keeping your blood sugar controlled.”

ANS: C
Clients with long-standing diabetes mellitus are at risk for pyelonephritis for many reasons. Chronically elevated blood glucose levels spill glucose into the urine, changing the pH and providing a favorable climate for bacterial growth. The neuropathy associated with diabetes reduces bladder tone and reduces the client’s sensation of bladder fullness. Thus, even with large amounts of urine, the client voids less frequently, allowing stasis and overgrowth of microorganisms. Increasing fluid intake (specifically water) and voiding frequently prevent stasis and bacterial overgrowth. Testing urine and using tampons will not help prevent pyelonephritis. A hemoglobin A1c of 9% is too high.

After teaching a client with nephrotic syndrome and a normal glomerular filtration, the nurse assesses the client’s understanding. Which statement made by the client indicates a correct understanding of the nutritional therapy for this condition?
a. “I must decrease my intake of fat.”
b. “I will increase my intake of protein.”
c. “A decreased intake of carbohydrates will be required.”
d. “An increased intake of vitamin C is necessary.”

ANS: B
In nephrotic syndrome, the renal loss of protein is significant, leading to hypoalbuminemia and edema formation. If glomerular filtration is normal or near normal, increased protein loss should be matched by increased intake of protein. The client would not need to adjust fat, carbohydrates, or vitamins based on this disorder.ANS: B
In nephrotic syndrome, the renal loss of protein is significant, leading to hypoalbuminemia and edema formation. If glomerular filtration is normal or near normal, increased protein loss should be matched by increased intake of protein. The client would not need to adjust fat, carbohydrates, or vitamins based on this disorder.

A nurse assesses a client who is recovering from a radical nephrectomy for renal cell carcinoma. The nurse notes that the client’s blood pressure has decreased from 134/90 to 100/56 mm Hg and urine output is 20 mL for this past hour. Which action should the nurse take?
a. Position the client to lay on the surgical incision.
b. Measure the specific gravity of the client’s urine.
c. Administer intravenous pain medications.
d. Assess the rate and quality of the client’s pulse.

ANS: D
The nurse should first fully assess the client for signs of volume depletion and shock, and then notify the provider. The radical nature of the surgery and the proximity of the surgery to the adrenal gland put the client at risk for hemorrhage and adrenal insufficiency. Hypotension is a clinical manifestation associated with both hemorrhage and adrenal insufficiency. Hypotension is particularly dangerous for the remaining kidney, which must receive adequate perfusion to function effectively. Re-positioning the client, measuring specific gravity, and administering pain medication would not provide data necessary to make an appropriate clinical decision, nor are they appropriate interventions at this time.

A nurse cares for a client who has pyelonephritis. The client states, “I am embarrassed to talk about my symptoms.” How should the nurse respond?
a. “I am a professional. Your symptoms will be kept in confidence.”
b. “I understand. Elimination is a private topic and shouldn’t be discussed.”
c. “Take your time. It is okay to use words that are familiar to you.”
d. “You seem anxious. Would you like a nurse of the same gender to care for you?”

ANS: C
Clients may be uncomfortable discussing issues related to elimination and the genitourinary area. The nurse should encourage the client to use language that is familiar to the client. The nurse should not make promises that cannot be kept, like keeping the client’s symptoms confidential. The nurse must assess the client and cannot take the time to stop the discussion or find another nurse to complete the assessment

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.

A 56-year-old female patient is admitted to the hospital with new onset nephrotic syndrome. Which assessment data will the nurse expect?

a.Poor skin turgor

b.Recent weight gain

c.Elevated urine ketones

d.Decreased blood pressure

ANS: B

The patient with a nephrotic syndrome will have weight gain associated with edema. Hypertension is a clinical manifestation of nephrotic syndrome. Skin turgor is normal because of the edema. Urine protein is high.

To prevent recurrence 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 28-year-old male patient is diagnosed with polycystic kidney disease. Which information is most appropriate for the nurse to include in teaching at this time?

a.Complications of renal transplantation

b.Methods for treating severe chronic pain

c.Discussion of options for genetic counseling

d.Differences between hemodialysis and peritoneal dialysis

ANS: C

Because a 28-year-old patient may be considering having children, the nurse should include information about genetic counseling when teaching the patient. The well-managed patient will not need to choose between hemodialysis and peritoneal dialysis or know about the effects of transplantation for many years. There is no indication that the patient has chronic pain.

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.

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.

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?

a.Blood in urine

b.Left flank bruising

c.Left flank discomfort

d.Decreased urine output

ANS: D

Because lithotripsy breaks the stone into small sand, which could cause obstruction, it is important to report a drop in urine output. Left flank pain, bruising, and hematuria are common after lithotripsy.

A 58-year-old male patient who weighs 242 lb (110 kg) undergoes a nephrectomy for massive kidney trauma due to a motor vehicle crash. Which postoperative assessment finding is most important to communicate to the surgeon?

a.Blood pressure is 102/58.

b.Urine output is 20 mL/hr for 2 hours.

c.Incisional pain level is reported as 9/10.

d.Crackles are heard at bilateral lung bases.

ANS: B

Because the urine output should be at least 0.5 mL/kg/hr, a 40 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. In addition, the nurse can medicate the patient for pain.

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

Nonsteroidal anti-inflammatory drugs (NSAIDs) should be avoided in patients with decreased renal function because nephrotoxicity is a potential adverse effect. The other orders do not need any clarification or change.

A 22-year-old female patient seen in the clinic for a bladder infection describes the following symptoms. Which information is most important for the nurse to report to the health care provider?

a.Urinary urgency

b.Left-sided flank pain

c.Intermittent hematuria

d.Burning with urination

ANS: B

Flank pain indicates that the patient may have developed pyelonephritis as a complication of the bladder infection. The other clinical manifestations are consistent with a lower urinary tract infection (UTI).

Which action will the nurse anticipate taking for an otherwise healthy 50-year-old who has just been diagnosed with Stage 1 renal cell carcinoma?

a.Prepare patient for a renal biopsy.

b.Provide preoperative teaching about nephrectomy.

c.Teach the patient about chemotherapy medications.

d.Schedule for a follow-up appointment in 3 months.

ANS: B

The treatment of choice in patients with localized renal tumors who have no co-morbid conditions is partial or total nephrectomy. A renal biopsy will not be needed in a patient who has already been diagnosed with renal cancer. Chemotherapy is used for metastatic renal cancer. Because renal cell cancer frequently metastasizes, treatment will be started as soon as possible after the diagnosis.

A patient is admitted to the emergency department with possible renal trauma after an automobile accident. Which prescribed intervention will the nurse implement first?

a.Check blood pressure and heart rate.

b.Administer morphine sulfate 4 mg IV.

c.Transport to radiology for an intravenous pyelogram.

d.Insert a urethral catheter and obtain a urine specimen.

ANS: A

Because the kidney is very vascular, the initial action with renal trauma will be assessment for bleeding and shock. The other actions are also important once the patient’s cardiovascular status has been determined and stabilized.

After change-of-shift report, which patient should the nurse assess first?

a.Patient with a urethral stricture who has not voided for 12 hours

b.Patient who has cloudy urine after orthotopic bladder reconstruction

c.Patient with polycystic kidney disease whose blood pressure is 186/98 mm Hg

d.Patient who voided bright red urine immediately after returning from lithotripsy

ANS: A

The patient information suggests acute urinary retention, a medical emergency. The nurse will need to assess the patient and consider whether to insert a retention catheter. The other patients will also be assessed, but their findings are consistent with their diagnoses and do not require immediate assessment or possible intervention.