Nokea
In evaluating multiple clients with UTIs, the clinic nurse should identify which client to be at least risk for developing a UT1?
- A. A client with urethral mucosa damage
- B. A client with an altered mental condition
- C. A client with an altered metabolic state
- D. An immunocompromised client
Correct Answer: C
Rationale: An altered metabolic state, without specific risk factors like diabetes, poses the least risk for UTIs compared to mucosal damage, mental status changes, or immunosuppression.
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Which information regarding the care of a cutaneous ileal conduit should the nurse discuss with the client?
- A. Teach the client to instill a few drops of vinegar into the pouch.
- B. Tell the client the stoma should be slightly dusky colored.
- C. Inform the client large clumps of mucus are expected.
- D. Tell the client it is normal for the urine to be pink or red in color.
Correct Answer: C
Rationale: Mucus in the urine is expected with an ileal conduit due to intestinal mucosa in the conduit. Vinegar instillation is not standard, a dusky stoma indicates ischemia, and pink/red urine suggests bleeding, which is abnormal.
The client is diagnosed with an acute episode of ureteral calculi. Which client problem is priority when caring for this client?
- A. Fluid volume loss.
- B. Knowledge deficit.
- C. Impaired urinary elimination.
- D. Alteration in comfort.
Correct Answer: D
Rationale: Severe pain (alteration in comfort) is the priority in acute ureteral calculi, as it affects the client’s immediate well-being and requires prompt management. Fluid loss, urinary elimination, and knowledge are secondary.
The client has received IV solutions for three (3) days through a 20-gauge IV catheter placed in the left cephalic vein. On morning rounds, the nurse notes the IV site is tender to palpation and a red streak has formed. Which intervention should the nurse implement first?
- A. Start a new IV in the right hand.
- B. Discontinue the intravenous line.
- C. Complete an incident record.
- D. Place a warm washrag over the site.
Correct Answer: B
Rationale: Tenderness and a red streak indicate phlebitis or infection. Discontinuing the IV line prevents further complications. Starting a new IV, completing an incident report, or applying warmth are secondary actions.
The client diagnosed with renal calculi is admitted to the medical unit. Which intervention should the nurse implement first?
- A. Monitor the client’s urinary output.
- B. Assess the client’s pain and rule out complications.
- C. Increase the client’s oral fluid intake.
- D. Use a safety gait belt when ambulating the client.
Correct Answer: B
Rationale: Severe pain is a hallmark of renal calculi, and complications like obstruction or infection must be ruled out first. Pain assessment guides treatment. Monitoring output, increasing fluids, and using a gait belt are secondary.
The client is admitted to the emergency department after a gunshot wound to the abdomen. Which nursing intervention should the nurse implement first to prevent ARF?
- A. Administer normal saline IV.
- B. Take vital signs.
- C. Place client on telemetry.
- D. Assess abdominal dressing.
Correct Answer: A
Rationale: A gunshot wound can cause hypovolemia, leading to prerenal ARF. Administering normal saline IV restores volume and perfusion, preventing ARF. Vital signs, telemetry, and dressing assessment are important but secondary to fluid resuscitation.