Nokea
The client diagnosed with renal calculi is admitted to the medical unit. Which intervention should the nurse implement first?
- A. Monitor the client’s urinary output.
- B. Assess the client’s pain and rule out complications.
- C. Increase the client’s oral fluid intake.
- D. Use a safety gait belt when ambulating the client.
Correct Answer: B
Rationale: Severe pain is a hallmark of renal calculi, and complications like obstruction or infection must be ruled out first. Pain assessment guides treatment. Monitoring output, increasing fluids, and using a gait belt are secondary.
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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.
The nurse is preparing a plan of care for the client diagnosed with acute glomerulonephritis. Which statement is an appropriate long-term goal?
- A. The client will have a blood pressure within normal limits.
- B. The client will show no protein in the urine.
- C. The client will maintain normal renal function.
- D. The client will have clear lung sounds.
Correct Answer: C
Rationale: Maintaining normal renal function is the ultimate long-term goal for acute glomerulonephritis, as it indicates resolution of renal damage. Normal BP and no proteinuria are intermediate goals, and clear lung sounds are unrelated.
When the client complains about the bland taste of the food, the nurse appropriately recommends substituting salt with a bloodiness?
- A. Catsup
- B. Mustard
- C. Soy sauce
- D. Lemon juice
Correct Answer: D
Rationale: Lemon juice is a low-sodium flavor enhancer, suitable for a sodium-restricted diet, unlike catsup, mustard, or soy sauce.
When the client asks the nurse to clarify the surgeon's explanation of the procedure, which statement is most accurate?
- A. Your urine will be deposited in your small intestine.
- B. Urine will be eliminated with stool from the rectum.
- C. Urine will drain from an abdominal opening.
- D. Your urine will empty from a special catheter.
Correct Answer: C
Rationale: An ileal conduit diverts urine to an abdominal stoma, where it drains externally.
Which information regarding the care of a cutaneous ileal conduit should the nurse discuss with the client?
- A. Teach the client to instill a few drops of vinegar into the pouch.
- B. Tell the client the stoma should be slightly dusky colored.
- C. Inform the client large clumps of mucus are expected.
- D. Tell the client it is normal for the urine to be pink or red in color.
Correct Answer: C
Rationale: Mucus in the urine is expected with an ileal conduit due to intestinal mucosa in the conduit. Vinegar instillation is not standard, a dusky stoma indicates ischemia, and pink/red urine suggests bleeding, which is abnormal.