Nokea
Before administering an analgesic to the client, which information is most important for the nurse to assess?
- A. Whether the urine is bloody
- B. Whether the client has been up walking in the room
- C. Whether the catheter is draining urine
- D. Whether the client has been drinking adequate fluids
Correct Answer: C
Rationale: Ensuring the catheter is draining urine is critical to prevent bladder distention, which could exacerbate discomfort.
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When the nurse reviews the client's medical history, which finding most likely precipitated the present illness?
- A. A recent streptococcal throat infection
- B. A recent influenza infection
- C. A recent episode of gastroenteritis
- D. A recent urinary tract infection
Correct Answer: A
Rationale: A recent streptococcal throat infection is a common trigger for acute glomerulonephritis due to immune-mediated kidney damage.
The elderly client is diagnosed with chronic glomerulonephritis. Which laboratory value indicates to the nurse the condition has become worse?
- A. The blood urea nitrogen is 15 mg/dL.
- B. The creatinine level is 1.2 mg/dL.
- C. The glomerular filtration rate is 40 mL/min.
- D. The 24-hour creatinine clearance is 100 mL/min.
Correct Answer: C
Rationale: A GFR of 40 mL/min indicates significant renal impairment, suggesting worsening chronic glomerulonephritis. Normal BUN (15 mg/dL), creatinine (1.2 mg/dL), and creatinine clearance (100 mL/min) do not reflect deterioration.
The male client diagnosed with metastatic cancer of the bladder is emaciated and refuses to eat. Which nursing action is an example of the ethical principle of paternalism?
- A. The nurse allows the client to talk about not wanting to eat.
- B. The nurse tells the client if he does not eat, a feeding tube will be placed.
- C. The nurse consults the dietitian about the client’s nutritional needs.
- D. The nurse asks the family to bring favorite foods for the client to eat.
Correct Answer: B
Rationale: Paternalism involves acting in the client’s best interest without their consent. Threatening a feeding tube overrides the client’s refusal to eat. Allowing discussion, consulting a dietitian, or involving family respect autonomy.
Which response by the nurse is most appropriate?
- A. His bladder retraining is coming along, and before long he will be urinating like normal.
- B. He seems to have more incontinence in the afternoon and evening.
- C. In order to protect his privacy, I can't give you that information.
- D. Bladder retraining is slow work. We have to take him to the toilet every 2 hours.
Correct Answer: C
Rationale: To comply with HIPAA, the nurse must protect the client's privacy and not disclose health information without consent, making this the most appropriate response.
After inserting an indwelling catheter into a male client, which technique is most appropriate for stabilizing the catheter to avoid damage to the penis?
- A. Tape the catheter to the abdomen.
- B. Pass the catheter under the client's leg.
- C. Fasten the drainage tubing to the bed with a safety pin.
- D. I'm very the catheter into the tubing of a collecting bag.
Correct Answer: A
Rationale: Taping the catheter to the abdomen stabilizes it without causing traction or damage to the penis, promoting comfort and safety.