Nokea
The client has received IV solutions for three (3) days through a 20-gauge IV catheter placed in the left cephalic vein. On morning rounds, the nurse notes the IV site is tender to palpation and a red streak has formed. Which intervention should the nurse implement first?
- A. Start a new IV in the right hand.
- B. Discontinue the intravenous line.
- C. Complete an incident record.
- D. Place a warm washrag over the site.
Correct Answer: B
Rationale: Tenderness and a red streak indicate phlebitis or infection. Discontinuing the IV line prevents further complications. Starting a new IV, completing an incident report, or applying warmth are secondary actions.
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Which intervention should the nurse implement when caring for the client with a nephrostomy tube?
- A. Change the dressing only if soiled by urine.
- B. Clean the end of the connecting tubing with Betadine.
- C. Clean the drainage system every day with bleach and water.
- D. Assess the tube for kinks to prevent obstruction.
Correct Answer: D
Rationale: Assessing for kinks ensures patency of the nephrostomy tube, preventing urine backup and complications. Dressings are changed regularly, Betadine is not used for tubing, and bleach cleaning is inappropriate.
The client is diagnosed with an acute episode of ureteral calculi. Which client problem is priority when caring for this client?
- A. Fluid volume loss.
- B. Knowledge deficit.
- C. Impaired urinary elimination.
- D. Alteration in comfort.
Correct Answer: D
Rationale: Severe pain (alteration in comfort) is the priority in acute ureteral calculi, as it affects the client’s immediate well-being and requires prompt management. Fluid loss, urinary elimination, and knowledge are secondary.
When the client with an ileal conduit asks about resuming physical activity, which response by the nurse is most appropriate?
- A. Avoid all strenuous activity permanently.
- B. Resume activities gradually as tolerated.
- C. Wait at least 6 months before exercising.
- D. Limit activity to walking only.
Correct Answer: B
Rationale: Resuming activities gradually as tolerated allows the client to regain strength while protecting the stoma.
Which statements made by the client's spouse most closely correlate with the diagnosis of acute glomerulonephritis? Select all that apply.
- A. My spouse's face looks rather puffy lately.
- B. Recently my spouse has been quite forgetful.
- C. My spouse has been salting food heavily.
- D. My spouse has been eating very well.
- E. My spouse hasn't been eating very well.
- F. My spouse gets up at night to use the bathroom.
Correct Answer: A,F
Rationale: Facial puffiness and nocturia are symptoms of glomerulonephritis, reflecting fluid retention and impaired kidney function.
In evaluating multiple clients with UTIs, the clinic nurse should identify which client to be at least risk for developing a UT1?
- A. A client with urethral mucosa damage
- B. A client with an altered mental condition
- C. A client with an altered metabolic state
- D. An immunocompromised client
Correct Answer: C
Rationale: An altered metabolic state, without specific risk factors like diabetes, poses the least risk for UTIs compared to mucosal damage, mental status changes, or immunosuppression.