Nokea
Immediately after the dialysate solution has been instilled, which nursing action is correct?
- A. Clamping the tubing from the infusion
- B. Draining the infused dialysate solution
- C. Restricting the client's movement as much as possible
- D. Encouraging the client to drink fluids
Correct Answer: A
Rationale: Clamping the tubing after instillation allows the dialysate to dwell, facilitating the exchange of waste products.
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The client is admitted to a nursing unit from a long-term care facility with a hematocrit of 56% and a serum sodium level of 152 mEq/L. Which condition is a cause for these findings?
- A. Overhydration.
- B. Anemia.
- C. Dehydration.
- D. Renal failure.
Correct Answer: C
Rationale: Elevated hematocrit (56%) and hypernatremia (152 mEq/L) indicate dehydration, which concentrates blood components and sodium. Overhydration dilutes these values, anemia lowers hematocrit, and renal failure typically causes hyponatremia.
The nurse is caring for clients on a renal surgery unit. After the afternoon report, which client should the nurse assess first?
- A. The male client who just returned from a CT scan who states he left his glasses in the x-ray department.
- B. The client who is one (1) day postoperative and has a moderate amount of serous drainage on the dressing.
- C. The client who is scheduled for surgery in the morning and wants an explanation of the operative procedure before signing the permit.
- D. The client who had ileal conduit surgery this morning and has not had any drainage in the drainage bag.
Correct Answer: D
Rationale: No drainage in the ileal conduit bag post-surgery suggests obstruction or complications, risking urine backup and renal damage. This is critical. Lost glasses, serous drainage, and surgical education are less urgent.
Which nursing intervention is most helpful in assisting the client undergoing hemodialysis to cope with the treatment?
- A. Giving the client literature to read about renal failure
- B. Advising the client's spouse to cook the client's favorite dishes
- C. Keeping the client informed of the latest research findings
- D. Exploring with the client how this disorder has affected life
Correct Answer: D
Rationale: Exploring the impact of the disorder on the client's life fosters emotional coping and supports psychosocial adjustment.
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 client is experiencing urinary incontinence. Which intervention should the nurse implement?
- A. Teach the client to drink prune juice weekly.
- B. Encourage the client to eat a high-fiber diet.
- C. Discuss the need to urinate every six (6) hours.
- D. Explain the importance of wearing cotton underwear.
Correct Answer: B
Rationale: A high-fiber diet prevents constipation, which can exacerbate incontinence by pressuring the bladder. Prune juice is too specific, voiding every 6 hours is too infrequent, and cotton underwear is secondary.