Nokea
A nurse obtains a sterile urine specimen from a client's Foley catheter. After applying a clamp to the drainage tubing distal to the injection port, which action should the nurse take next?
- A. Clamp another section of the tube to create a fixed sample section for retrieval.
- B. Insert a syringe into the injection port and aspirate the quantity of urine required.
- C. Clean the injection port cap of the drainage tubing with a povidone-iodine solution.
- D. Withdraw 10 mL of urine and discard it; then withdraw a fresh sample of urine.
Correct Answer: C
Rationale: The correct next action for the nurse to take after applying a clamp to the drainage tubing distal to the injection port is to clean the injection port cap of the catheter drainage tubing with an appropriate antiseptic like povidone-iodine solution or alcohol. This step is crucial to prevent surface contamination before taking the urine sample. Clamping another section of the tube to create a fixed sample section or withdrawing and discarding urine are unnecessary and could lead to potential contamination. Inserting a syringe into the injection port and aspirating the required amount of urine directly from the catheter is the correct method for obtaining the urine sample, but cleaning the injection port cap should precede this step to ensure sterility.
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A client has just had a central line catheter placed that is specific for hemodialysis. What is the most appropriate action by the nurse?
- A. Use the catheter for the next laboratory blood draw.
- B. Monitor the central venous pressure through this line.
- C. Access the line for the next intravenous medication.
- D. Place a heparin or heparin/saline dwell after hemodialysis.
Correct Answer: D
Rationale: The most appropriate action for the nurse after a central line catheter placement for hemodialysis is to place a heparin or heparin/saline dwell after hemodialysis treatment. This helps prevent clot formation in the line and maintain patency for future use. Using the catheter for blood draws is not recommended as it may increase the risk of infection. Monitoring central venous pressure is not indicated with this type of catheter. Accessing the line for medications is also not recommended to prevent complications and ensure the line is solely used for hemodialysis purposes.
After a renal biopsy, which intervention should the nurse include in the post-procedure plan of care?
- A. Restricting fluid intake for the first 24 hours
- B. Periodically testing the urine for occult blood
- C. Avoiding the administration of opioid analgesics
- D. Having the client ambulate in the room and hall for short distances
Correct Answer: B
Rationale: After a renal biopsy, it is essential to maintain bed rest and frequently assess the client's vital signs and the puncture site. The nurse should test the urine periodically for occult blood to detect any bleeding, which could be a complication of the procedure. Restricting fluid intake for the first 24 hours is not necessary after a renal biopsy and could potentially lead to dehydration. Avoiding the administration of opioid analgesics is not a standard intervention post-renal biopsy unless contraindicated for a specific reason. Having the client ambulate in the room and hall for short distances is generally not recommended immediately after a renal biopsy due to the need for bed rest to prevent complications.
A nurse is assessing a postoperative client on an hourly basis. The nurse notes that the client's urine output for the past hour was 25 mL. Based on this finding, the nurse first:
- A. Calls the physician
- B. Increases the rate of the IV infusion
- C. Checks the client's overall intake and output record
- D. Administers a 250-mL bolus of normal saline solution (0.9%)
Correct Answer: C
Rationale: Clients are at risk of hypovolemia postoperatively, and decreased urine output can be an early sign. However, to accurately interpret this finding, the nurse must assess the overall fluid balance by checking the client's intake and output records. Increasing the IV infusion rate or administering a bolus of normal saline solution without a physician's order would not be appropriate as these interventions require a prescription. The physician should be notified once the nurse has collected all necessary assessment data, including fluid status and vital signs.
A nurse assesses a client who is recovering from a radical nephrectomy for renal cell carcinoma. The nurse notes that the client's blood pressure has decreased from 134/90 to 100/56 mm Hg and urine output is 20 mL for this past hour. Which action should the nurse take?
- A. Position the client to lay on the surgical incision.
- B. Measure the specific gravity of the client's urine.
- C. Administer intravenous pain medications.
- D. Assess the rate and quality of the client's pulse.
Correct Answer: D
Rationale: The nurse should first fully assess the client for signs of volume depletion and shock, and then notify the provider. The radical nature of the surgery and the proximity of the surgery to the adrenal gland put the client at risk for hemorrhage and adrenal insufficiency. Hypotension is a clinical manifestation associated with both hemorrhage and adrenal insufficiency. Hypotension is particularly dangerous for the remaining kidney, which must receive adequate perfusion to function effectively. Re-positioning the client, measuring specific gravity, and administering pain medication would not provide data necessary to make an appropriate clinical decision, nor are they appropriate interventions at this time.
A client recently diagnosed with chronic kidney disease (CKD) is receiving discharge instructions from a nurse. Which statements made by the client indicate a correct understanding of the teaching? (Select all that apply.)
- A. I need to ask for an antibiotic when scheduling a dental appointment.
- B. I'll need to check my blood sugar often to prevent hypoglycemia.
- C. The dose of my pain medication may have to be adjusted.
- D. The need to watch for bleeding with anticoagulants.
Correct Answer: A
Rationale: The correct statements indicating a proper understanding of the teaching include the need for antibiotics for dental work, the potential need to adjust pain medication doses, and the importance of monitoring blood sugar levels. The statement about watching for bleeding with anticoagulants is not directly related to CKD and discharge instructions for this condition. Therefore, option A is correct, as it addresses relevant concerns for a client with CKD, while the other options are either unrelated or not specifically mentioned in the scenario.