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The client diagnosed with a urinary tract infection has a blood pressure of 83/56 mm Hg and a pulse of 122 bpm. Which should the nurse implement first?
- A. Notify the health-care provider (HCP).
- B. Hang the IVPB antibiotic at the prescribed rate.
- C. Check the laboratory work to determine if the urine culture has been completed.
- D. Increase the normal saline IV fluids from keep open to 150 mL/hour on the IV pump.
Correct Answer: D
Rationale: Hypotension (83/56) and tachycardia (122 bpm) suggest septic shock from the UTI. Increasing IV fluids to 150 mL/hour improves perfusion, stabilizing the client. Notification, antibiotics, and lab checks are secondary to immediate fluid resuscitation.
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On the basis of the nurse's knowledge of patient rights, which Federal law has the PCT violated?
- A. Good samarian Act
- B. Uncontractic Oath
- C. Health Insurance Portability and Accountability Act (HIPAA)
- D. Emergency Medical Treatment and Liability Act (EMTALA)
Correct Answer: C
Rationale: The PCT violated HIPAA by discussing the client's condition loudly in a public area, compromising patient confidentiality.
The client diagnosed with CKD has a new arteriovenous fistula in the left forearm. Which intervention should the nurse implement?
- A. Teach the client to carry heavy objects with the right arm.
- B. Perform all laboratory blood tests on the left arm.
- C. Instruct the client to lie on the left arm during the night.
- D. Discuss the importance of not performing any hand exercises.
Correct Answer: A
Rationale: To protect the new AV fistula, the client should avoid stress on the left arm. Carrying heavy objects with the right arm prevents fistula damage. Blood tests should avoid the fistula arm, lying on it risks compression, and hand exercises are encouraged to promote fistula maturation.
Which intervention should the nurse implement for the client who has had an ileal conduit?
- A. Pouch the stoma with a one (1)-inch margin around the stoma.
- B. Refer the client to the United Ostomy Association for discharge teaching.
- C. Report to the health-care provider any decrease in urinary output.
- D. Monitor the stoma for signs and symptoms of infection every shift.
Correct Answer: D
Rationale: Monitoring the stoma for infection (e.g., redness, discharge) prevents complications. Pouching requires a precise fit, not a 1-inch margin; ostomy referrals are secondary; and decreased output is monitored but not always reported immediately.
Which nursing intervention is most important to add to the client's care plan after removal of the suprapubic catheter?
- A. Check the client's urine specific gravity every shift.
- B. Measure the client's abdominal girth daily.
- C. Change wet abdominal dressings as needed.
- D. Perform a credé maneuver every 4 hours.
Correct Answer: C
Rationale: Changing wet dressings prevents infection and promotes healing at the suprapubic site.
The nurse is inserting an indwelling catheter into a female client. Which interventions should be implemented? Rank in the order of performance.
- A. Explain the procedure to the client.
- B. Set up the sterile field.
- C. Inflate the catheter bulb.
- D. Place absorbent pads under the client.
- E. Clean the perineum from clean to dirty with Betadine.
Correct Answer: A,D,B,E,C
Rationale: Correct order: 1) Explain the procedure to gain consent and reduce anxiety; 2) Place absorbent pads to maintain a clean field; 3) Set up the sterile field to prepare equipment; 4) Clean the perineum (front to back, not clean to dirty, assuming document error) to reduce infection risk; 5) Inflate the catheter bulb after insertion to secure it.