Nokea
The client diagnosed with renal calculi is scheduled for a 24-hour urine specimen collection. Which interventions should the nurse implement? Select all that apply.
- A. Check for the ordered diet and medication modifications.
- B. Instruct the client to urinate, and discard this urine when starting collection.
- C. Collect all urine during 24 hours and place in appropriate specimen container.
- D. Insert an indwelling catheter in client after having the client empty the bladder.
- E. Instruct the UAP to notify the nurse when the client urinates.
Correct Answer: A,B,C
Rationale: For a 24-hour urine collection, ensure diet/medication orders are followed, discard the first void to start the collection period, and collect all subsequent urine. Catheters are unnecessary, and UAP notification is not standard.
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The nurse is caring for a client diagnosed with rule-out nephrotic syndrome. Which intervention should be included in the plan of care?
- A. Monitor the urine for bright-red bleeding.
- B. Evaluate the calorie count of the 500-mg protein diet.
- C. Assess the client’s sacrum for dependent edema.
- D. Monitor for a high serum albumin level.
Correct Answer: C
Rationale: Nephrotic syndrome is characterized by massive proteinuria, hypoalbuminemia, and edema, often dependent (e.g., in the sacrum in bedridden clients). Assessing for dependent edema is a key intervention to monitor disease progression or response to treatment. Bright-red bleeding is not typical, a 500-mg protein diet is incorrect, and high serum albumin is not expected.
The client receiving dialysis is complaining of being dizzy and light-headed. Which action should the nurse implement first?
- A. Place the client in the Trendelenburg position.
- B. Turn off the dialysis machine immediately.
- C. Bolus the client with 500 mL of normal saline.
- D. Notify the health-care provider as soon as possible.
Correct Answer: B
Rationale: Dizziness and light-headedness during dialysis suggest hypotension, often due to rapid fluid removal. Turning off the dialysis machine stops fluid removal, stabilizing the client. Trendelenburg, saline bolus, or notifying the provider are secondary actions.
The client is admitted with a serum sodium level of 110 mEq/L. Which nursing intervention should be implemented?
- A. Encourage fluids orally.
- B. Administer 10% saline solution IVPB.
- C. Administer antidiuretic hormone intranasally.
- D. Place on seizure precautions.
Correct Answer: D
Rationale: Severe hyponatremia (110 mEq/L) increases seizure risk due to cerebral edema. Seizure precautions are the priority to ensure safety. Oral fluids or ADH may worsen hyponatremia, and 10% saline is not standard.
Because of the client's impaired urine elimination, which potential skin problem will require additional team planning?
- A. Reduced perspiration
- B. Extreme oiliness
- C. Loss of skin turgor
- D. Pronounced itching
Correct Answer: D
Rationale: Pronounced itching is a common skin problem in renal failure due to uremia and phosphate accumulation.
The client is reporting chills, fever, and left costovertebral pain. Which diagnostic test should the nurse expect the HCP to prescribe first?
- A. A midstream urine for culture.
- B. A sonogram of the kidney.
- C. An intravenous pyelogram for renal calculi.
- D. A CT scan of the kidneys.
Correct Answer: A
Rationale: Chills, fever, and costovertebral pain suggest pyelonephritis. A midstream urine culture is the first test to identify the causative organism. Imaging (sonogram, IVP, CT) is secondary to confirm complications or other diagnoses.