Nokea
A client with acute renal failure has metabolic acidosis. The nurse expects:
- A. Sodium bicarbonate administration.
- B. Increased potassium intake.
- C. Fluid bolus.
- D. High-protein diet.
Correct Answer: A
Rationale: Sodium bicarbonate corrects metabolic acidosis in acute renal failure.
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The nurse is assessing the urine of a client who has had an ileal conduit and notes that the urine is yellow with a moderate amount of mucus. Based on the data, the nurse should?
- A. Change the appliance bag.
- B. Notify the physician.
- C. Obtain a urine specimen for culture.
- D. Encourage a high fluid intake.
Correct Answer: D
Rationale: Yellow urine with moderate mucus is normal for an ileal conduit due to intestinal segment use. Encouraging high fluid intake prevents complications like calculi or infection.
A 57-year-old client has difficulty with mobility after cancer treatment therapies and states, 'Why should I bother stretching my muscles? It doesn't seem to make any difference what I do.' The nurse responds by helping the client establish reasonable activity goals, choose their own health care from the menu, and make choices about her daily activities. These interventions represent the nurse's attempt to address which of the following nursing diagnoses?
- A. Ineffective coping.
- B. Powerlessness.
- C. Risk prone health behavior.
- D. Complicated grieving.
Correct Answer: B
Rationale: The client's statement reflects powerlessness, and the nurse's interventions aim to restore a sense of control through goal-setting and decision-making.
The client is scheduled to have a kidney, ureter, and bladder (KUB) radiograph. To prepare the client for this procedure, the nurse should explain to the client that:
- A. Fluid and food will be withheld the morning of the examination.
- B. A tranquilizer will be given before the examination.
- C. An enema will be given before the examination.
- D. No special preparation is required for the examination.
Correct Answer: D
Rationale: A KUB radiograph requires no special preparation, as it is a non-invasive imaging test to locate renal calculi.
A client is recovering from an abdominal-perineal resection. Which of the following measures would most effectively promote wound healing after the perineal drains have been removed?
- A. Taking sitz baths several times a day.
- B. Applying a moist heat pack to the wound.
- C. Performing perineal irrigations.
- D. Packing the wound with sterile gauze.
Correct Answer: A
Rationale: Sitz baths promote wound healing by improving circulation, reducing inflammation, and keeping the perineal area clean after an abdominal-perineal resection. Moist heat packs, irrigations, or packing are less effective or not standard for this purpose. CN: Physiological adaptation; CL: Synthesize
Which is a priority assessment for the client in shock who is receiving an I.V. infusion of packed red blood cells and normal saline solution?
- A. Fluid balance.
- B. Anaphylactic reaction.
- C. Pain.
- D. Altered level of consciousness.
Correct Answer: B
Rationale: During a blood transfusion in a client in shock, the priority assessment is for an anaphylactic reaction, as transfusion reactions can be life-threatening and require immediate intervention. Fluid balance, pain, and consciousness are monitored but are secondary.