Nokea
Considering the amount of time the client must remain in bed, why is it imperative for the nurse to monitor for a urinary tract infection?
- A. The client will not be able to complete hygiene needs.
- B. The client will not be able to fully empty the bladder.
- C. The client will not be able to maintain bladder control.
- D. The client will not be able to drink sufficient fluids.
Correct Answer: B
Rationale: Prolonged bed rest can lead to incomplete bladder emptying, increasing the risk of urinary stasis and subsequent urinary tract infections.
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The nurse is caring for the client recovering from a percutaneous renal biopsy. Which data indicate the client is complying with client teaching?
- A. The client is lying flat in the saline position.
- B. The client continues oral fluids restriction while on bedrest.
- C. The client uses the bedside commode to urinate.
- D. The client refuses to ask for any pain medication.
Correct Answer: A
Rationale: Post-renal biopsy, lying flat (supine, assuming 'saline' is a typo) prevents bleeding complications, indicating compliance. Fluid restriction is unnecessary, using a commode risks bleeding, and refusing pain meds is unrelated.
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 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.
When performing a physical assessment, which sensation would the nurse expect to detect when palpating the site of the arteriovenous fistula?
- A. A pulse
- B. A bruit
- C. A thrill
- D. A click
Correct Answer: C
Rationale: A thrill, a buzzing sensation, is expected when palpating a functioning arteriovenous fistula, indicating proper blood flow.
If this client's condition is similar to that of others in the oliguric phase of renal failure, the nurse would anticipate the client's urine output to be within what range?
- A. 50 to 100 mL/hour
- B. 100 to 150 mL/hour
- C. 500 to 1,000 mL/day
- D. 100 to 500 mL/day
Correct Answer: D
Rationale: The oliguric phase of renal failure is characterized by a urine output of 100–500 mL/day, reflecting significantly reduced kidney function.