Nokea
A client has a ureteral catheter in place after renal surgery. A priority nursing action for care of the ureteral catheter would be to:
- A. Irrigate the catheter with 30 mL of normal saline every 8 hours.
- B. Ensure that the catheter is draining freely.
- C. Clamp the catheter every 2 hours for 30 minutes.
- D. Ensure that the catheter drains at least 30 mL/hour.
Correct Answer: B
Rationale: Ensuring free drainage prevents obstruction or pressure buildup, which could harm the surgical site or kidney function.
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A client who had received 25 mL of packed red blood cells (PRBCs) has low back pain and pruritus. After stopping the infusion, the nurse should take what action next?
- A. Administer prescribed antihistamine and aspirin.
- B. Collect blood and urine samples and send to the lab.
- C. Administer prescribed diuretics.
- D. Administer prescribed vasopressors.
Correct Answer: B
Rationale: Low back pain and pruritus after 25 mL of PRBCs suggest a transfusion reaction, likely hemolytic or allergic. After stopping the infusion, the nurse should collect blood and urine samples to assess for hemolysis (e.g., free hemoglobin in plasma or urine). Antihistamines may be administered later for allergic symptoms, but lab samples are the priority. Diuretics and vasopressors are not indicated.
A client with acute renal failure reports shortness of breath. The nurse should:
- A. Administer oxygen.
- B. Increase fluid intake.
- C. Check lung sounds.
- D. Encourage coughing.
Correct Answer: C
Rationale: Shortness of breath may indicate fluid overload; lung sounds assess for pulmonary edema.
A client has an amylase level of 450 units/L and lipase level of 659 units/L. The client has mid-epigastric pain with nausea. What assessment helps the nurse to determine severity of the client's condition?
- A. Ranson's criteria.
- B. Vital signs.
- C. Urine output.
- D. Glasgow Coma Scale.
Correct Answer: A
Rationale: Ranson's criteria (A) assess pancreatitis severity based on lab and clinical findings (e.g., age, white blood cell count, glucose). Vital signs (B) and urine output (C) are important but less specific. Glasgow Coma Scale (D) is for neurological assessment, not pancreatitis.
The client is scheduled for an intravenous pyelogram (IVP) to determine the location of the renal calculi. Which of the following measures would be most important for the nurse to include in pretest preparation?
- A. Ensuring adequate fluid intake on the day of the test.
- B. Preparing the client for the possibility of bladder, the client is history for allergy to iodine.
- C. Determining when the client last had a bowel movement.
Correct Answer: B
Rationale: Checking for iodine allergy is critical for IVP due to the use of iodine-based contrast, which can cause severe allergic reactions.
The nurse is caring for a client with a fractured pelvis in pelvic traction. Which activity is contraindicated?
- A. Log rolling to change positions.
- B. Deep breathing exercises.
- C. Using a trapeze for repositioning.
- D. Applying moisturizer to the skin.
Correct Answer: A
Rationale: Log rolling is contraindicated in pelvic traction to maintain alignment and prevent displacement.