Nokea
It is most appropriate for the nurse to advise the client that taking this medication will have which effect on the urine?
- A. The urine will look cloudy.
- B. The urine will appear orange.
- C. The urine will become scant.
- D. The urine will have a strong odor.
Correct Answer: B
Rationale: Phenazopyridine (Pyridium) commonly causes the urine to turn orange, which is a harmless side effect that the client should be informed about.
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Which nursing assessment is essential to add to the client's care plan?
- A. Monitor body temperature.
- B. Measure intake and output.
- C. Assess for urine retention.
- D. Check the urine for glucose.
Correct Answer: B
Rationale: Measuring intake and output is critical in renal failure to monitor fluid balance and kidney function.
Which intervention is most important for the nurse to implement for the client with a left nephrectomy?
- A. Assess the intravenous fluids for rate and volume.
- B. Change surgical dressing every day at the same time.
- C. Monitor the client’s PT/PTT/INR level daily.
- D. Monitor the percentage of each meal eaten.
Correct Answer: A
Rationale: Post-nephrectomy, maintaining adequate hydration and perfusion to the remaining kidney is critical to prevent acute kidney injury. Assessing IV fluid rate and volume ensures proper fluid balance. Dressing changes, coagulation monitoring, and meal intake are less urgent.
The client is two (2) days postureterosigmoidostomy for cancer of the bladder. Which assessment data warrant notification of the HCP by the nurse?
- A. The client complains of pain at a '3,' 30 minutes after being medicated.
- B. The client complains it hurts to cough and deep breathe.
- C. The client ambulates to the end of the hall and back before lunch.
- D. The client is lying in a fetal position and has a rigid abdomen.
Correct Answer: D
Rationale: A rigid abdomen and fetal position suggest peritonitis or other serious complications (e.g., anastomotic leak) post-ureterosigmoidostomy, requiring immediate HCP notification. Mild pain, coughing discomfort, and ambulation are less urgent.
The male client diagnosed with CKD has received the initial dose of erythropoietin, a biologic response modifier, one (1) week ago. Which complaint by the client indicates the need to notify the health-care provider?
- A. The client complains of flu-like symptoms.
- B. The client complains of being tired all the time.
- C. The client reports an elevation in his blood pressure.
- D. The client reports discomfort in his legs and back.
Correct Answer: C
Rationale: Erythropoietin can cause hypertension as a side effect, which is significant in CKD patients and warrants notifying the provider. Flu-like symptoms and fatigue are common and expected, while leg/back discomfort is less specific.
Which intervention should the nurse implement first for the client who has had an incontinent episode?
- A. Palpate the client’s bladder to assess for urinary retention.
- B. Obtain a bedside commode for the client.
- C. Assist the client with changing the wet clothes.
- D. Request the UAP to change the client’s linens.
Correct Answer: C
Rationale: Assisting the client to change wet clothes addresses immediate comfort and dignity, preventing skin breakdown. Palpating the/moist bladder, obtaining a commode, or changing linens are secondary.