Nokea
A nurse is assigned to care for a client with a cutaneous ureterostomy. Which of the following images correlates with the client's urinary diversion?
- A. Image A
- B. Image B
- C. Image C
- D. Image D
Correct Answer: C
Rationale: A cutaneous ureterostomy involves the ureters being brought to the skin surface, typically depicted as a stoma on the abdomen, which corresponds to a specific image (assumed as C based on standard depictions).
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The male client diagnosed with CKD has received the initial dose of erythropoietin, a biologic response modifier, one (1) week ago. Which complaint by the client indicates the need to notify the health-care provider?
- A. The client complains of flu-like symptoms.
- B. The client complains of being tired all the time.
- C. The client reports an elevation in his blood pressure.
- D. The client reports discomfort in his legs and back.
Correct Answer: C
Rationale: Erythropoietin can cause hypertension as a side effect, which is significant in CKD patients and warrants notifying the provider. Flu-like symptoms and fatigue are common and expected, while leg/back discomfort is less specific.
If this client shares cultural characteristics of other Native Americans, which findings in the cultural assessment should be included in the client's care plan? Select all that apply.
- A. Native Americans may hesitate to share personal information with strangers.
- B. Questions regarding health history may be interpreted as prying.
- C. Native Americans value listening skills.
- D. Touching on the head is considered offensive.
- E. Native Americans pattern their lifestyle according to 'clock time.'
- F. Direct eye contact should be used when addressing the client or family.
Correct Answer: A,B,C
Rationale: These cultural characteristics reflect common Native American values and should guide culturally sensitive care.
The female client in an outpatient clinic is being sent home with a diagnosis of urinary tract infection (UTI). Which instruction should the nurse teach to prevent a recurrence of a UTI?
- A. Clean the perineum from back to front after a bowel movement.
- B. Take warm tub baths instead of hot showers daily.
- C. Void immediately preceding sexual intercourse.
- D. Avoid coffee, tea, colas, and alcoholic beverages.
Correct Answer: D
Rationale: Avoiding bladder irritants like coffee, tea, colas, and alcohol reduces UTI recurrence risk. Wiping back to front increases infection risk, tub baths are less effective than showers, and voiding before intercourse is less critical than after.
The client is two (2) days postureterosigmoidostomy for cancer of the bladder. Which assessment data warrant notification of the HCP by the nurse?
- A. The client complains of pain at a '3,' 30 minutes after being medicated.
- B. The client complains it hurts to cough and deep breathe.
- C. The client ambulates to the end of the hall and back before lunch.
- D. The client is lying in a fetal position and has a rigid abdomen.
Correct Answer: D
Rationale: A rigid abdomen and fetal position suggest peritonitis or other serious complications (e.g., anastomotic leak) post-ureterosigmoidostomy, requiring immediate HCP notification. Mild pain, coughing discomfort, and ambulation are less urgent.
The nurse is preparing the plan of care for a client with fluid volume deficit. Which interventions should the nurse include in the plan of care? Select all that apply.
- A. Monitor vital signs every two (2) hours until stable.
- B. Monitor the client’s oral intake and urinary output daily.
- C. Administer mouth care when bathing the client.
- D. Weigh the client weekly in the same clothing at the same time.
- E. Assess skin turgor and mucous membranes every shift.
Correct Answer: A,B,E
Rationale: For fluid volume deficit, monitor vital signs frequently for stability, track intake/output daily to assess hydration, and assess skin turgor/mucous membranes for dehydration. Weekly weights are too infrequent, and mouth care during bathing is not specific.