Nokea
As the nurse instructs the client about CBI, which information should the nurse provide? Select all that apply.
- A. You may feel the urge to urinate even though the bladder is empty.
- B. Do not to try to urinate around the catheter, because this will cause bladder spasms.
- C. You need to limit your fluids to 4 glasses per day.
- D. It is normal for the urine to be bloody immediately after surgery.
- E. The catheter will be removed in about a week.
- F. By the time you are ready to go home, your urine should be pink with a few clots.
Correct Answer: A,B,D,F
Rationale: These statements accurately describe CBI effects, expectations, and precautions post-TURP.
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Which diagnostic test, considered a sensitive indicator of advanced kidney disease, will need to be closely monitored by the nursing team?
- A. Serum creatinine level
- B. Serum sodium level
- C. Uric acid level
- D. Urine specific gravity
Correct Answer: A
Rationale: Serum creatinine is a sensitive indicator of kidney function, as it rises with advanced kidney disease due to impaired filtration.
Which intervention should the nurse implement for the client who has had an ileal conduit?
- A. Pouch the stoma with a one (1)-inch margin around the stoma.
- B. Refer the client to the United Ostomy Association for discharge teaching.
- C. Report to the health-care provider any decrease in urinary output.
- D. Monitor the stoma for signs and symptoms of infection every shift.
Correct Answer: D
Rationale: Monitoring the stoma for infection (e.g., redness, discharge) prevents complications. Pouching requires a precise fit, not a 1-inch margin; ostomy referrals are secondary; and decreased output is monitored but not always reported immediately.
Which nursing intervention promotes the spontaneous passage of ureteral stones?
- A. Encouraging ambulation as tolerated
- B. Restricting fluid intake
- C. Administering diuretics
- D. Keeping the client on bed rest
Correct Answer: A
Rationale: Encouraging ambulation promotes gravity-assisted stone movement through the ureter, facilitating spontaneous passage.
The nurse is developing a plan of care for a client diagnosed with ARF. Which statement is an appropriate outcome for the client?
- A. Monitor intake and output every shift.
- B. Decrease of pain by three (3) levels on a 1-to-10 scale.
- C. Electrolytes are within normal limits.
- D. Administer enemas to decrease hyperkalemia.
Correct Answer: C
Rationale: An appropriate outcome for ARF is achieving normal electrolyte levels, as imbalances like hyperkalemia are common. Monitoring intake/output and administering enemas are interventions, not outcomes, and pain reduction is less specific to ARF.
Which information indicates to the nurse the client teaching about treatment of urinary incontinence has been effective?
- A. The client prepares a scheduled voiding plan.
- B. The client verbalizes the need to increase fluid intake.
- C. The client explains how to perform pelvic floor exercises.
- D. The client attempts to retain the vaginal cone in place the entire day.
Correct Answer: C
Rationale: Pelvic floor (Kegel) exercises strengthen muscles to reduce incontinence, indicating effective teaching. Scheduled voiding is a strategy, increased fluids may worsen incontinence, and vaginal cones are not used all day.