Nokea
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.
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A nurse cares for a client with autosomal dominant polycystic kidney disease (ADPKD). The client asks, 'Will my children develop this disease?' How should the nurse respond?
- A. No genetic link is present, so your children are not at increased risk.
- B. Your sons will develop this disease because it has a sex-linked gene.
- C. Only if both you and your spouse are carriers of this disease.
- D. Your children have a 50% chance of inheriting the gene that causes this disease.
Correct Answer: D
Rationale: ADPKD is an autosomal dominant disorder, meaning there is a 50% chance of passing the gene to each child, regardless of gender. It is not sex-linked, and only one parent needs to have the gene for the child to be at risk.
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.
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.
A nurse cares for a middle-aged female client with diabetes mellitus who is being treated for the third episode of acute pyelonephritis in the past year. The client asks, 'What can I do to help prevent these infections?' How should the nurse respond?
- A. Test your urine daily for the presence of ketone bodies and proteins.
- B. Use tampons rather than sanitary napkins during your menstrual period.
- C. Drink more water and empty your bladder more frequently during the day.
- D. Keep your hemoglobin A1C under 9% by keeping your blood sugar controlled.
Correct Answer: C
Rationale: Increasing fluid intake (especially water) and frequent voiding help flush bacteria from the urinary tract, reducing the risk of pyelonephritis. Chronically elevated blood glucose in diabetes can promote bacterial growth, but frequent voiding is the most direct preventive measure. Testing urine for ketones/proteins, using tampons, or controlling hemoglobin A1C are not as directly related to preventing urinary tract infections.
A nurse assesses a client who has a family history of polycystic kidney disease (PKD). For which clinical manifestations should the nurse assess? (Select all that apply.)
- A. Nocturia
- B. Dysuria
- C. Increased abdominal girth
- D. Dyspnea
- E. Hematuria
- F. Diarrhea
Correct Answer: B,C,E
Rationale: Clients with PKD commonly experience dysuria, increased abdominal girth due to kidney enlargement, and hematuria from cyst rupture or tissue damage. Nocturia, dyspnea, and diarrhea are not typically associated with PKD.