Nokea
A nurse on a medical-surgical unit cares for a client who has just undergone a procedure for a Kock pouch as a treatment for bladder cancer. The initial nursing interventions for this client would include:
- A. Monitoring urine output, checking for indications of ostomy pouch leaks, and noting the size, shape, and color of the stoma.
- B. Speaking to the client's family and updating them regarding the client's status.
- C. Educating the client about stoma care and skincare.
- D. Irrigating the catheters as needed.
Correct Answer: A
Rationale: Initial interventions for a Kock pouch include monitoring urine output and stoma condition to ensure proper function and detect complications.
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The nurse is assessing a client receiving peritoneal dialysis. Which laboratory result should immediately be reported to the primary healthcare provider (PHCP)?
- A. WBC 19,000 mm3 [5,000-10,000 mm3]
- B. Hemoglobin 9 g/dL [Male: 14-18 g/dL (140-180 g/L) Female: 12-16 g/dL (120-160 g/L)]
- C. Calcium 8.6 mg/dL [9.0-10.5 mg/dL]
- D. Serum pH 7.33 [7.35-7.45]
Correct Answer: A
Rationale: Elevated WBC (19,000 mm3) suggests infection, a serious complication in peritoneal dialysis.
The nurse is caring for a client who was newly prescribed warfarin. Which medication on the client's medication list requires follow-up with the primary healthcare provider (PHCP)?
- A. Loratadine
- B. Saw Palmetto
- C. Furosemide
- D. Pantoprazole
Correct Answer: B
Rationale: Saw Palmetto can interact with warfarin by potentially increasing bleeding risk due to its antiplatelet effects, requiring follow-up with the PHCP. Loratadine (A), Furosemide (C), and Pantoprazole (D) have minimal interactions with warfarin.
The nurse cares for a client with a potassium of 3.1 mEq/L (mmol/L) [3.5-5 mEq/L, mmol/L]. The primary healthcare provider (PHCP) prescribed 40 mEq of intravenous (IV) potassium over four hours. Which assessment finding would indicate a therapeutic effect?
- A. normoactive bowel sounds
- B. flattened T-waves
- C. reduced deep tendon reflexes
- D. muscle cramping
Correct Answer: B
Rationale: Hypokalemia can cause peaked T-waves on ECG. A therapeutic effect of potassium administration would be normalization of ECG, indicated by flattened T-waves. Normoactive bowel sounds (A), reduced reflexes (C), and muscle cramping (D) are not specific indicators of corrected hypokalemia.
The nurse is caring for a 68-year-old individual in the emergency department who had been on the bathroom floor for about 10 hours after a fall. While performing straight catheterization, the nurse notes that the urine output reaches 800 mL and continues to flow heavily. What action should the nurse take, and what is the rationale for this action?
- A. Drain the client's bladder entirely and place a small amount in a urine specimen cup. This client needs a urine sample to check for rhabdomyolysis.
- B. Continue draining the bladder fully, then place a Foley catheter to monitor for sufficient urine output.
- C. Stop draining the client's bladder because the client is at risk for developing bladder spasms.
- D. Stop draining the client's bladder to prevent the risk of urinary tract infection (UTI) and notify the primary healthcare provider (PHCP) for further instructions.
Correct Answer: A
Rationale: Prolonged immobility increases rhabdomyolysis risk, requiring a urine sample to check for myoglobin.
The nurse is caring for a client who is severely hypernatremic. The nurse should prioritize assessing the client's
- A. cardiovascular status.
- B. genitourinary status.
- C. neurological status.
- D. gastrointestinal status.
Correct Answer: C
Rationale: Hypernatremia affects neurological status due to cellular dehydration, causing confusion, seizures, or coma, requiring priority assessment.