Nokea
Because the client also has diabetes mellitus, which statement by the nurse best explains why that client is at higher risk for a training in a bladder infection?
- A. Glucose in urine supports bacterial growth.
- B. Diabetes suppresses white blood cell activity.
- C. Diabetic clients urinate more frequently.
- D. The urine is more concentrated in diabetic clients.
Correct Answer: A
Rationale: Glucose in the urine, common in diabetes, provides a nutrient-rich environment that promotes bacterial growth, increasing infection risk.
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The nurse is admitting a client diagnosed with acute renal failure (ARF). Which question is most important for the nurse to ask during the admission interview?
- A. Have you recently traveled outside the United States?
- B. Did you recently begin a vigorous exercise program?
- C. Is there a chance you have been exposed to a virus?
- D. What over-the-counter medications do you take regularly?
Correct Answer: D
Rationale: Acute renal failure can be caused by nephrotoxic agents, including over-the-counter medications like NSAIDs. Asking about medication use identifies potential causes of ARF, which is more directly relevant than travel, exercise, or viral exposure.
The client is admitted with a serum sodium level of 110 mEq/L. Which nursing intervention should be implemented?
- A. Encourage fluids orally.
- B. Administer 10% saline solution IVPB.
- C. Administer antidiuretic hormone intranasally.
- D. Place on seizure precautions.
Correct Answer: D
Rationale: Severe hyponatremia (110 mEq/L) increases seizure risk due to cerebral edema. Seizure precautions are the priority to ensure safety. Oral fluids or ADH may worsen hyponatremia, and 10% saline is not standard.
The nurse is observing the UAP providing direct care to a client with an indwelling catheter. Which data warrant immediate intervention by the nurse?
- A. The UAP secures the tubing to the client’s leg with tape.
- B. The UAP provides catheter care with the client’s bath.
- C. The UAP puts the collection bag on the client’s bed.
- D. The UAP cares for the catheter after washing the hands.
Correct Answer: C
Rationale: Placing the collection bag on the bed risks contamination and infection, as it should be below bladder level and off surfaces. Securing tubing, providing care during bathing, and hand washing are appropriate.
The client is NPO and is receiving total parenteral nutrition (TPN) via a subclavian line. Which precautions should the nurse implement? Select all that apply.
- A. Place the solution on an IV pump at the prescribed rate.
- B. Monitor blood glucose every six (6) hours.
- C. Weigh the client weekly, first thing in the morning.
- D. Change the IV tubing every three (3) days.
- E. Monitor intake and output every shift.
Correct Answer: A,B,E
Rationale: TPN requires an IV pump for precise delivery, frequent glucose monitoring due to high dextrose content, and intake/output monitoring to assess fluid balance. Weekly weights and tubing changes every 3 days are less critical or incorrect.
The nurse is discharging a client with a healthcare facility acquired urinary tract infection. Which information should the nurse include in the discharge teaching?
- A. Limit fluid intake so the urinary tract can heal.
- B. Collect a routine urine specimen for culture.
- C. Take all the antibiotics as prescribed.
- D. Tell the client to void every five (5) to six (6) hours.
Correct Answer: C
Rationale: Completing the full course of antibiotics prevents recurrence and resistance in UTIs. Limiting fluids increases infection risk, routine cultures are unnecessary, and voiding every 2–3 hours is preferred.