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A client is admitted for postoperative assessment and recovery after surgery for a kidney tumor. The nurse needs to assess for signs of urinary tract infection. Which of the ff measures can be used to help detect UTI?
- A. Encourage the client to breathe deeply and cough every 2hrs
- B. Monitor temperature every 4hrs
- C. Splint the incision when repositioning the client
- D. Irrigate tubes as ordered CARING FOR CLIENTS WITH DISORDERS OF THE BLADDER AND URETHRA
Correct Answer: B
Rationale: The correct answer is B: Monitor temperature every 4hrs. This is crucial in detecting signs of urinary tract infection as fever is a common symptom. Monitoring temperature regularly allows for early detection and appropriate intervention.
A: Encouraging the client to breathe deeply and cough every 2hrs is a measure to prevent respiratory complications postoperatively, not related to UTI detection.
C: Splinting the incision when repositioning the client is important for wound care, not for detecting UTI.
D: Irrigating tubes as ordered is a specific intervention for tube care, not for monitoring UTI symptoms.
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Which of the following examples of client data needs to be validated?
- A. A client has trouble reading an informed consent, but states he does not need glasses.
- B. An elderly client explains that the black and blue marks on his arms and legs are due to a fall.
- C. A nurse examining a client with a respiratory infection documents fever and chills.
- D. A client in a nursing home states that she is unable to eat the food being served.
Correct Answer: A
Rationale: The correct answer is A because validating the client's statement about not needing glasses is crucial for accurate data collection. This step ensures that the client's difficulty reading is not due to poor eyesight.
- Choice B is about interpreting physical signs, not client data validation.
- Choice C involves documenting objective findings, not validating client information.
- Choice D pertains to a client's complaint, not necessarily requiring validation.
To supplement a diet with foods high in potassium, the nurse should recommend the addition of:
- A. Fruits such as bananas
- B. Milk and yogurt
- C. Green leafy vegetables
- D. Nuts and legumes
Correct Answer: A
Rationale: The correct answer is A: Fruits such as bananas. Bananas are high in potassium, which is essential for various bodily functions like muscle contractions and maintaining fluid balance. Fruits are a natural source of potassium and are easily incorporated into the diet. Milk and yogurt (B) are good sources of calcium, not potassium. Green leafy vegetables (C) are nutritious but may not provide as much potassium as fruits. Nuts and legumes (D) are good sources of protein and healthy fats but are not as rich in potassium as fruits like bananas.
A nurse has been caring for a client with chronic obstructive pulmonary disease (COPD). What should the nurse focus on during the evaluation phase?
- A. Documenting all interventions performed
- B. Reviewing the client’s progress toward meeting goals
- C. Delegating further care to another healthcare professional
- D. Ensuring compliance with all physician orders
Correct Answer: B
Rationale: The correct answer is B because during the evaluation phase of nursing care for a client with COPD, the nurse should review the client's progress toward meeting the goals set during the planning phase. This involves assessing whether the interventions implemented are effective in improving the client's condition and if the goals are being achieved. This step is crucial in determining the overall effectiveness of the care provided and making any necessary adjustments to the plan.
A: Documenting interventions is important but not the primary focus during the evaluation phase.
C: Delegating further care is not typically done during the evaluation phase as it is more about assessing the current care plan.
D: Ensuring compliance with physician orders is important but does not encompass the holistic evaluation of the client's progress towards goals.
The nurse is caring for a patient who has an open wound and is evaluating the progress of wound healing. Which priority action will the nurse take?
- A. Ask the nursing assistive personnel if the wound looks better.
- B. Document the progress of wound healing as “better” in the chart.
- C. Measure the wound and observe for redness, swelling, or drainage.
- D. Leave the dressing off the wound for easier access and more frequent assessments.
Correct Answer: C
Rationale: The correct answer is C because measuring the wound and observing for redness, swelling, or drainage are essential steps in evaluating wound healing progress. Measuring the wound provides objective data on its size changes, while observing for signs of infection like redness, swelling, or drainage helps identify complications.
- Choice A is incorrect because the nursing assistive personnel may not have the necessary knowledge to assess wound healing accurately.
- Choice B is incorrect because documenting progress as "better" without objective data is subjective and does not provide a clear picture of the wound status.
- Choice D is incorrect because leaving the dressing off can expose the wound to contaminants and compromise healing, making it a potentially harmful action.
For a patient receiving furosemide, the nurse evaluates the medication as being effective if which of the following effects occurs?
- A. Urine output increased
- B. Heart rate increased
- C. Serum potassium decreased
- D. Pulse pressure increased
Correct Answer: A
Rationale: The correct answer is A: Urine output increased. Furosemide is a loop diuretic that works by increasing urine output, thus helping to reduce fluid volume in the body. This effect is crucial in managing conditions like heart failure and edema. Increased urine output indicates that the medication is working as intended.
Choice B: Heart rate increased is incorrect as furosemide does not directly affect heart rate.
Choice C: Serum potassium decreased is incorrect as furosemide can lead to potassium loss, but this is not the primary indicator of its effectiveness.
Choice D: Pulse pressure increased is incorrect as furosemide does not typically impact pulse pressure.