Nokea
Because of the client's impaired urine elimination, which potential skin problem will require additional team planning?
- A. Reduced perspiration
- B. Extreme oiliness
- C. Loss of skin turgor
- D. Pronounced itching
Correct Answer: D
Rationale: Pronounced itching is a common skin problem in renal failure due to uremia and phosphate accumulation.
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The nurse is assessing a client diagnosed with urethral strictures. Which data support the diagnosis?
- A. Complaints of frequency and urgency.
- B. Clear yellow drainage from the urethra.
- C. Complaints of burning during urination.
- D. A diminished force and stream during voiding.
Correct Answer: D
Rationale: Urethral strictures obstruct urine flow, causing a diminished force and stream. Frequency, urgency, and burning suggest UTI, and clear drainage is unrelated.
The client who is postoperative TURP asks the nurse, 'When will I know if I will be able to have sex after my TURP?' Which response is most appropriate by the nurse?
- A. You seem anxious about your surgery.'
- B. Tell me about your fears of impotency.'
- C. Potency can return in six (6) to eight (8) weeks.'
- D. Did you ask your doctor about your concern?'
Correct Answer: C
Rationale: Sexual function typically resumes 6–8 weeks post-TURP, providing a direct and reassuring answer. Other responses avoid the question or assume anxiety without addressing the concern.
When preparing the client for catheterization, how should the nurse position the client?
- A. Lithotomy position
- B. Recumbent
- C. Knee-chest position
- D. Prone
Correct Answer: A
Rationale: The lithotomy position provides optimal access to the urethral meatus for catheterization in female clients.
The nurse is preparing the plan of care for the client diagnosed with a neurogenic flaccid bladder. Which expected outcome is appropriate for this client?
- A. The client has conscious control over bladder activity.
- B. The client’s bladder does not become overdistended.
- C. The client has bladder sensation and no discomfort.
- D. The client demonstrates how to check for bladder distention.
Correct Answer: B
Rationale: A neurogenic flaccid bladder lacks tone, risking overdistention. Preventing this is a key outcome to avoid complications like infection or reflux. Conscious control and sensation are unlikely, and checking distention is an intervention.
Which nursing intervention is most appropriate when the nurse is changing the appliance of the client's ileal conduit?
- A. When you remove the appliance, let the urine drip into a container.
- B. When you remove the appliance, insert a tampon into the stoma.
- C. When you remove the appliance, press a gloved finger over the stoma.
- D. When you remove the appliance, pinch the stoma with two fingers.
Correct Answer: C
Rationale: Pressing a gloved finger over the stoma prevents urine leakage during appliance changes, maintaining hygiene and skin integrity.