Nokea
The client diagnosed with cancer of the bladder is scheduled to have a cutaneous urinary diversion procedure. Which preoperative teaching intervention specific to the procedure should be included?
- A. Demonstrate turn, cough, and deep breathing.
- B. Explain a bag will drain the urine from now on.
- C. Instruct the client on the use of a PCA pump.
- D. Take the client to the ICD so the client can become familiar with it.
Correct Answer: B
Rationale: A cutaneous urinary diversion (e.g., ileal conduit) requires a stoma and drainage bag. Explaining this prepares the client for post-op care. Coughing/breathing, PCA use, and ICU visits are general, not specific.
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The male client diagnosed with CKD secondary to diabetes has been receiving dialysis for 12 years. The client is notified he will not be placed on the kidney transplant list. The client tells the nurse he will not be back for any more dialysis treatments. Which response by the nurse is most therapeutic?
- A. You cannot just quit your dialysis. This is not an option.'
- B. You’re angry at not being on the list, and you want to quit dialysis?'
- C. I will call your nephrologist right now so you can talk to the HCP.'
- D. Make your funeral arrangements because you are going to die.'
Correct Answer: B
Rationale: A therapeutic response acknowledges the client’s emotions and encourages discussion. Reflecting anger and the desire to quit dialysis validates feelings and opens dialogue. Other options are dismissive, confrontational, or non-therapeutic.
The nurse is caring for a client diagnosed with rule-out ARF. Which condition predisposes the client to developing prerenal failure?
- A. Diabetes mellitus.
- B. Hypotension.
- C. Aminoglycosides.
- D. Benign prostatic hypertrophy.
Correct Answer: B
Rationale: Prerenal failure results from decreased renal perfusion. Hypotension reduces blood flow to the kidneys, directly causing prerenal ARF. Diabetes and aminoglycosides contribute to intrinsic renal damage, while BPH causes postrenal issues.
The client diagnosed with CKD is receiving peritoneal dialysis. Which assessment data warrant immediate intervention by the nurse?
- A. Inability to auscultate a bruit over the fistula.
- B. The client’s abdomen is soft, is nontender, and has bowel sounds.
- C. The dialysate being removed from the client’s abdomen is clear.
- D. The dialysate instilled was 1,500 mL and removed was 1,500 mL.
Correct Answer: A
Rationale: Peritoneal dialysis does not involve a fistula, so inability to auscultate a bruit suggests a documentation error or confusion with hemodialysis, requiring immediate clarification. Soft abdomen, clear dialysate, and equal instill/removal volumes are normal findings.
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.
Which statement by the client with an ileal conduit indicates a need for further teaching?
- A. I will change the pouch every 5 to 7 days.
- B. I will keep the skin around the stoma clean and dry.
- C. I will empty the pouch when it is one-third full.
- D. I will avoid drinking fluids to reduce urine output.
Correct Answer: D
Rationale: Avoiding fluids is incorrect, as adequate fluid intake is necessary to maintain urine flow and prevent complications.