Nur 215 Medical Surgical 1

Correct Answer:

Bright red blood in urine

Explanation:

Bright red blood in the urine following a cystoscopy may indicate active bleeding and should be reported immediately. While some mild hematuria (pink-tinged urine) is expected, bright red bleeding suggests a complication such as trauma or vessel injury during the procedure. This finding requires prompt evaluation by the provider to rule out serious issues and initiate appropriate treatment. It goes beyond expected post-procedure symptoms.

Why Other Options Are Wrong:

Urinary frequency

This is a common and expected side effect after cystoscopy due to bladder irritation. It typically resolves without intervention and does not signal a serious complication.

Pink-tinged urine

Mild hematuria is normal post-procedure and results from minor mucosal irritation. It usually subsides within a day or two and doesn’t require reporting unless it worsens.

Burning on urination

Dysuria can occur after cystoscopy as the urethra may be irritated. This symptom should be monitored, but it is not necessarily a complication unless accompanied by signs of infection or worsening discomfort.

Correct Answer:

Receive an annual influenza vaccination

Explanation:

Preventing infections is a critical part of managing myasthenia gravis because illnesses such as the flu can trigger a myasthenic crisis—a life-threatening exacerbation of muscle weakness. An annual influenza vaccination helps protect patients from respiratory infections that may compromise respiratory muscles already weakened by the disease. Vaccination is a proactive step to reduce the risk of systemic illness and serious complications. It is a key aspect of long-term disease management.

Why Other Options Are Wrong:

Wear gloves when handling frozen food items

This may help with conditions like Raynaud’s phenomenon, but it has no direct impact on preventing myasthenic crisis. It is unrelated to infection control or neuromuscular health in this context.

Avoid warm climates

While heat may cause discomfort or fatigue in some patients with neurological conditions, avoiding warm climates is not a primary or evidence-based intervention to prevent myasthenic crisis.

Increase intake of protein

Protein is important for general health but is not specifically linked to preventing myasthenic crisis. The focus should be on avoiding infection and managing medications, not adjusting macronutrient intake unless prescribed for another reason.

Correct Answer:

Glomerulus

Explanation:

Proteinuria, or the presence of excess protein in the urine, typically indicates damage to the glomerulus. The glomerulus acts as a filter in the nephron, allowing waste products to pass while retaining larger molecules like proteins. Damage to this filtration barrier allows proteins to leak into the urine, which is a hallmark of glomerular injury.

Why Other Options Are Wrong:

Renal artery

While the renal artery supplies blood to the kidney, it is not directly involved in filtration. Damage here would affect perfusion but not cause protein leakage unless it results in downstream glomerular damage.

Collecting ducts

The collecting ducts primarily function in water and electrolyte reabsorption under hormonal control. They do not filter blood or retain protein, so damage here would not result in proteinuria.

Loop of Henle

This structure plays a role in concentrating urine by reabsorbing water and salts. It does not serve as a filtration site for proteins, so damage here is unlikely to result in protein in the urine.

Correct Answer:

Decrease in elasticity on skin turgor is a normal part of aging

Explanation:

As people age, their skin loses collagen and elastin, leading to decreased skin elasticity. This normal aging process affects the reliability of skin turgor assessment as a measure of hydration. The nurse must understand that reduced skin turgor in older adults does not necessarily indicate dehydration, especially if assessed on the back of the hand. Instead, the clavicle or sternum area may give a more accurate picture. Recognizing these physiological changes helps prevent misinterpretation during assessment.

Why Other Options Are Wrong:

Older adults skin turgor is moist and boggy

This is inaccurate. Normal skin turgor in older adults is not described as moist or boggy. “Boggy” often refers to tissue swelling or infection, and moisture level does not define turgor. This description mischaracterizes normal aging changes in skin.

Skin turgor is unaffected by aging

This is incorrect because aging significantly affects skin elasticity. With age, the dermis thins and connective tissue breaks down, which reduces skin's ability to return to its normal shape quickly. This makes turgor assessments less reliable if not adjusted for age-related changes.

Assessment should only be performed on the hands of the older adults

This is false. In older adults, hand skin turgor is not reliable due to loss of subcutaneous tissue. Nurses should assess skin turgor over areas such as the sternum or forehead for a more accurate hydration status in older adults.

Correct Answer:

Teach female patients to wipe from front to back after urinating

Explanation:

Wiping from front to back is a key hygienic practice to prevent bacterial contamination of the urinary tract, especially in females due to the proximity of the urethra to the anus. This method reduces the risk of transferring fecal bacteria such as E. coli into the urethra, which is a common cause of urinary tract infections. It is a simple and highly effective preventive measure that should be routinely taught during patient education. Promoting proper perineal hygiene can significantly decrease UTI incidence.

Why Other Options Are Wrong:

Encourage patients to drink at least 8 ounces of water every hour

While increasing fluid intake can help flush the urinary system, drinking 8 ounces every hour is excessive and unrealistic for most patients. Overhydration can lead to complications, especially in those with heart or kidney issues. Proper hydration should be tailored to individual needs.

Instruct patients to use bath powder to absorb perineal perspiration

Bath powder may help with moisture but does not address bacterial contamination or reduce UTI risk. In some cases, powders can even irritate the skin or promote yeast growth if not used appropriately.

Advise patients to hold urine as long as possible

Holding urine for extended periods increases the risk of urinary stasis and bacterial growth, leading to infection. Encouraging timely voiding is a more appropriate strategy to prevent UTIs.

Correct Answer:

Avoiding unnecessary catheterization

Using catheter sampling port for obtaining urine culture

Using aseptic technique when inserting the catheter

Placing securement device on the inner thigh

Explanation:

To prevent catheter-associated urinary tract infections (CAUTIs), clinical guidelines recommend minimizing catheter use, maintaining a closed sterile system, and following proper insertion and maintenance techniques. Avoiding unnecessary catheterization reduces exposure risk. Sampling from the catheter port rather than the drainage bag ensures a sterile sample. Aseptic technique during insertion helps prevent pathogen introduction. Securement devices reduce urethral trauma and movement, which can decrease the risk of infection.

Why Other Options Are Wrong:

Changing urinary catheter every three days

Routine catheter changes at fixed intervals (like every three days) are not recommended. Instead, catheters should be changed based on clinical indications such as obstruction, infection, or when no longer needed. Changing too frequently can increase infection risk due to repeated entry into the system.

Correct Answer:

Keep active, use stress-reduction strategies and avoid fatigue

Explanation:

Even for patients on bed rest, encouraging as much activity as tolerated helps reduce complications like muscle atrophy, pressure injuries, and respiratory issues. For patients with an indwelling catheter, stress and fatigue can also impair immune function and recovery. Stress-reduction and energy conservation strategies are essential to preserve physical and mental well-being during limited mobility. Maintaining a positive, proactive approach to care supports recovery.

Why Other Options Are Wrong:

Follow good health habits to change the course of the disease

This does not directly address the immediate nursing concern for a patient with a catheter and on bed rest. It is vague and not a priority intervention.

Practice using the mechanical aids that you will need with future disabilities arise

This statement assumes future decline and is not patient-centered or timely. The focus should be on current needs and abilities.

You will need to accept the necessity of a quiet and inactive lifestyle

This promotes passivity and can worsen physical deconditioning. Bed rest should be managed with interventions that promote safe mobility and prevent complications.

Correct Answer:

Strike a flat hand covering the costovertebral angle (CVA)

Explanation:

Assessment for costovertebral angle (CVA) tenderness is a standard method for evaluating flank pain, often associated with kidney infection such as pyelonephritis. The nurse places one hand flat over the CVA region and strikes it with the fist of the other hand. A positive response is pain or discomfort, indicating possible inflammation or infection in the kidney. This is a quick, non-invasive method to support diagnostic decisions.

Why Other Options Are Wrong:

Palpate along both sides of the lumbar vertebral column

Palpation can assess muscle or skeletal tenderness but is not specific or reliable for evaluating kidney inflammation or infection.

Push fingers upward into the two lowest intercostal spaces

This technique is not relevant to kidney assessment. It may be used in abdominal exams but does not target the CVA where the kidneys are located.

Percuss between the iliac crest and ribs at the midaxillary line

Although this area may be near the CVA, this technique does not accurately localize kidney tenderness and is not the standard method for assessing flank pain related to pyelonephritis.

Correct Answer:

It does not alter the underlying disease process, but it may improve a client’s quality of life

Explanation:

Carbidopa/levodopa is a cornerstone medication for managing the symptoms of Parkinson’s disease. It does not modify or reverse the disease itself, as Parkinson’s is a progressive neurodegenerative disorder. Instead, the medication helps restore dopamine balance in the brain, which can significantly reduce motor symptoms such as tremors, stiffness, and slowness of movement. By relieving symptoms, it can greatly enhance the patient's quality of life even though the disease continues to progress.

Why Other Options Are Wrong:

It will send the disease into remission and eventually cure the disease

This is inaccurate because Parkinson’s disease is chronic and progressive. There is currently no known cure or remission phase for the disease, and medications only manage symptoms. This option creates a false sense of expectation about treatment outcomes.

It will control the symptoms for 10 to 12 years

While carbidopa/levodopa is initially effective, its long-term use is often associated with diminishing returns and complications like motor fluctuations and dyskinesias. The specific duration of symptom control varies and is not guaranteed for 10–12 years.

It is the treatment of last resort and may control symptoms

Carbidopa/levodopa is actually considered first-line therapy in many cases, especially when symptoms significantly impair functioning. Labeling it as a “treatment of last resort” is misleading and clinically incorrect.