Nokea
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.
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The elderly client is diagnosed with chronic glomerulonephritis. Which laboratory value indicates to the nurse the condition has become worse?
- A. The blood urea nitrogen is 15 mg/dL.
- B. The creatinine level is 1.2 mg/dL.
- C. The glomerular filtration rate is 40 mL/min.
- D. The 24-hour creatinine clearance is 100 mL/min.
Correct Answer: C
Rationale: A GFR of 40 mL/min indicates significant renal impairment, suggesting worsening chronic glomerulonephritis. Normal BUN (15 mg/dL), creatinine (1.2 mg/dL), and creatinine clearance (100 mL/min) do not reflect deterioration.
Which data support to the nurse the client’s diagnosis of acute bacterial prostatitis?
- A. Terminal dribbling.
- B. Urinary frequency.
- C. Stress incontinence.
- D. Sudden fever and chills.
Correct Answer: D
Rationale: Acute bacterial prostatitis presents with sudden systemic symptoms like fever and chills, often with dysuria. Terminal dribbling, frequency, and incontinence are more typical of BPH or chronic conditions.
Before administering an analgesic to the client, which information is most important for the nurse to assess?
- A. Whether the urine is bloody
- B. Whether the client has been up walking in the room
- C. Whether the catheter is draining urine
- D. Whether the client has been drinking adequate fluids
Correct Answer: C
Rationale: Ensuring the catheter is draining urine is critical to prevent bladder distention, which could exacerbate discomfort.
Which dietary recommendation should the nurse provide to the client to prevent the recurrence of calcium oxalate stones?
- A. Increase intake of leafy green vegetables
- B. Limit intake of oxalate-rich foods
- C. Avoid all protein-rich foods
- D. Decrease fluid intake
Correct Answer: B
Rationale: Limiting oxalate-rich foods (e.g., spinach, nuts) reduces the formation of calcium oxalate stones.
The nurse is preparing the plan of care for a client with fluid volume deficit. Which interventions should the nurse include in the plan of care? Select all that apply.
- A. Monitor vital signs every two (2) hours until stable.
- B. Monitor the client’s oral intake and urinary output daily.
- C. Administer mouth care when bathing the client.
- D. Weigh the client weekly in the same clothing at the same time.
- E. Assess skin turgor and mucous membranes every shift.
Correct Answer: A,B,E
Rationale: For fluid volume deficit, monitor vital signs frequently for stability, track intake/output daily to assess hydration, and assess skin turgor/mucous membranes for dehydration. Weekly weights are too infrequent, and mouth care during bathing is not specific.