Nokea
The client diagnosed with a fluid and electrolyte disturbance in the emergency department is exhibiting peaked T waves on the STAT electrocardiogram. Which interventions should the nurse implement? List in order of priority.
- A. Assess the client for leg and muscle cramps.
- B. Check the serum potassium level.
- C. Notify the health-care provider.
- D. Arrange for a transfer to the telemetry floor.
- E. Administer Kayexalate, a cation resin.
Correct Answer: B,C,E,D,A
Rationale: Peaked T waves indicate hyperkalemia. Priority: 1) Check potassium level to confirm; 2) Notify HCP for orders; 3) Administer Kayexalate to lower potassium; 4) Transfer to telemetry for monitoring; 5) Assess cramps, a less urgent symptom.
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When administering the bladder instillation containing the chemotherapeutic drug, which safety precaution is most important for the nurse to take?
- A. Wear two pairs of latex gloves.
- B. As a mass syringe for the drug.
- C. Avoid wearing clothing with long sleeves.
- D. Limit contact time with the client.
Correct Answer: A
Rationale: Wearing two pairs of latex gloves protects the nurse from exposure to the chemotherapeutic drug during instillation.
The nurse is planning the care of a postoperative client with an ileal conduit. Which intervention should be included in the plan of care?
- A. Provide meticulous skin care and pouching.
- B. Apply sterile drainage bags daily.
- C. Monitor the pH of the urine weekly.
- D. Assess the stoma site every day.
Correct Answer: A
Rationale: Meticulous skin care and proper pouching prevent skin breakdown and infection around the ileal conduit stoma. Sterile bags are unnecessary, weekly pH monitoring is not standard, and daily stoma assessment is part of skin care.
The client is in the intensive care department (ICD) after a motor-vehicle accident in which the client lost an estimated three (3) units of blood. Which action by the nurse could prevent the client from developing acute renal failure?
- A. Take and document the client’s vital signs every hour.
- B. Assess the client’s dressings every two (2) hours.
- C. Check the client’s urinary output every shift.
- D. Maintain the client’s blood pressure greater than 100/60.
Correct Answer: D
Rationale: Significant blood loss risks prerenal ARF due to hypoperfusion. Maintaining BP above 100/60 ensures adequate renal perfusion. Vital signs, dressing checks, and urine output monitoring are supportive but less preventive.
Which intervention is most important for the nurse to implement for the client diagnosed with rule-out renal calculi?
- A. Assess the client’s neurological status every two (2) hours.
- B. Strain all urine and send any sediment to the laboratory.
- C. Monitor the client’s creatinine and BUN levels.
- D. Take a 24-hour dietary recall during the client interview.
Correct Answer: B
Rationale: Straining urine to capture stones or sediment is critical for diagnosing renal calculi, as it confirms the presence and type of stones. Neurological status, lab monitoring, and dietary recall are secondary.
Which statements should be included when the nurse instructs a female client about the technique for collecting a clean-catch midstream urine specimen for routine urinalysis? Select all that apply.
- A. Clean the urethral area using several circular motions.
- B. Void into the plastic liner under the toilet seat.
- C. Void a small amount, and then collect a sample of urine.
- D. Mix the antiseptic solution with the collected urine specimen.
- E. Collect the urine in the nonsterile cup.
- F. Drink several caffeinated beverages before collecting the urine.
Correct Answer: A,C
Rationale: Cleaning the urethral area and voiding a small amount before collecting the sample ensure a clean-catch specimen, reducing contamination and ensuring accurate results.