Nokea
A nurse cares for a client who has pyelonephritis. The client states, 'I am embarrassed to talk about my symptoms and I don't want to talk to my nurse.' 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?
Correct Answer: C
Rationale: Encouraging the client to use familiar language helps facilitate discussion about sensitive genitourinary symptoms. Promising absolute confidentiality may not be feasible, dismissing the topic is inappropriate, and changing nurses does not address the client's discomfort with communication.
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A nurse reviews laboratory results for a client with glomerulonephritis. The client's glomerular filtration rate (GFR) is 40 ml/min as measured by a 24-hour creatinine clearance. How should the nurse interpret this finding? (Select all that apply.)
- A. Excessive GFR
- B. Normal GFR
- C. Reduced GFR
- D. Potential for fluid overload
- E. Potential for dehydration
Correct Answer: C,D
Rationale: A GFR of 40 ml/min is significantly reduced compared to the normal range of 100-120 ml/min, indicating impaired kidney function. This reduction increases the risk of fluid overload, leading to hypertension and pulmonary edema, rather than dehydration.
A nurse cares for a client with a nephrostomy tube and notes that the drainage has decreased. Which action should the nurse take first?
- A. Document the finding in the client's record.
- B. Evaluate the tube as working in the hand-off report.
- C. Clamp the tube in preparation for removing it.
- D. Assess the client's abdomen and vital signs.
Correct Answer: D
Rationale: Decreased drainage from a nephrostomy tube may indicate obstruction, necessitating immediate assessment of the client's abdomen for pain or distention and vital signs to detect complications like infection or obstruction. This information should be reported to the provider. Documenting, evaluating in hand-off, or clamping the tube are not appropriate initial actions.
An emergency department nurse cares for a client who is severely dehydrated and is prescribed 3 L of intravenous fluid over 6 hours. At what rate should the nurse set the intravenous pump to infuse the fluids? (Record your answer using a whole number.)
- A. 100 ml/hr
- B. 250 ml/hr
- C. 500 ml/hr
- D. 750 ml/hr
Correct Answer: C
Rationale: To deliver 3 L (3000 ml) over 6 hours, the infusion rate is calculated as 3000 ml ÷ 6 hours = 500 ml/hr. This rate ensures the prescribed volume is administered within the specified time frame.
A nurse teaches a client with polycystic kidney disease (PKD). Which statements should the nurse include in this client's discharge teaching? (Select all that apply.)
- A. Take your blood pressure every morning.
- B. Weigh yourself at the same time each day.
- C. Adjust your diet to prevent diarrhea.
- D. Contact your provider if you have visual disturbances.
- E. Assess your urine for renal stones.
Correct Answer: A,B,D
Rationale: Clients with PKD should monitor blood pressure and weight daily to track hypertension and fluid status, and report visual disturbances, which may indicate a berry aneurysm. Adjusting diet to prevent constipation, not diarrhea, is appropriate, and renal stones are not a primary concern in PKD.
After teaching a client with renal cancer who is prescribed temsirolimus (Torisel), the nurse assesses the client's understanding. Which statement made by the client indicates a correct understanding of the teaching?
- A. I will take this medication with food and plenty of water.
- B. I shall keep my appointment at the infusion center each week.
- C. I must limit my intake of green leafy vegetables while on this medication.
- D. I must not take this medication if I have an infection or am feeling ill.
Correct Answer: B
Rationale: Temsirolimus is administered weekly via intravenous infusion, so keeping infusion center appointments is correct. It is not taken orally, does not require dietary restrictions like limiting green leafy vegetables, and while infections should be reported, the statement about not taking it if ill is not accurate.