Nokea
The client diagnosed with renal calculi is scheduled for lithotripsy. Which postprocedure nursing task is the most appropriate to delegate to the UAP?
- A. Monitor the amount, color, and consistency of urine output.
- B. Teach the client about care of the indwelling Foley catheter.
- C. Assist the client to the car when being discharged home.
- D. Take the client’s postprocedural vital signs.
Correct Answer: C
Rationale: Assisting the client to the car is a non-clinical task within the UAP’s scope. Monitoring urine, teaching catheter care, and taking vital signs require nursing judgment and are not delegable.
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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.
Which nursing action is most appropriate when the client complains about being thirsty because of the fluid restrictions?
- A. Giving the client hard candy to suck
- B. Providing the client with ice chips
- C. Offering the client an ice cream bar
- D. Supplying the client with fresh fruit
Correct Answer: A
Rationale: Hard candy stimulates saliva production, alleviating thirst without contributing to fluid intake, which is restricted.
After inserting an indwelling catheter into a male client, which technique is most appropriate for stabilizing the catheter to avoid damage to the penis?
- A. Tape the catheter to the abdomen.
- B. Pass the catheter under the client's leg.
- C. Fasten the drainage tubing to the bed with a safety pin.
- D. I'm very the catheter into the tubing of a collecting bag.
Correct Answer: A
Rationale: Taping the catheter to the abdomen stabilizes it without causing traction or damage to the penis, promoting comfort and safety.
Which problem is the nurse's immediate concern after kidney transplant surgery?
- A. Risk for infection
- B. Fluid overload
- C. Hypotension
- D. Pain management
Correct Answer: A
Rationale: Risk for infection is the immediate concern post-transplant due to immunosuppression, which increases susceptibility to infections.
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.