Nokea
The client is 12 hours postoperative renal surgery. Which data warrant immediate intervention by the nurse?
- A. The abdomen is soft, nontender, and rounded.
- B. Pain is not felt with dorsal flexion of the foot.
- C. The urine output is 60 mL for the past two (2) hours.
- D. The client’s trough vancomycin level is 24 mcg/mL.
Correct Answer: D
Rationale: A vancomycin level of 24 mcg/mL is above the therapeutic range (10–20 mcg/mL), risking nephrotoxicity, especially post-renal surgery. Soft abdomen, no pain on dorsiflexion, and 60 mL urine output are normal.
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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.
The nurse is developing a care map to care for a client diagnosed with chronic renal failure (CRF) on hemodialysis. Which interrelated concepts should be included in the map? Select all that apply.
- A. Fluid and electrolytes.
- B. Hematologic regulation.
- C. Digestion.
- D. Metabolism.
- E. Mobility.
- F. Nutrition.
Correct Answer: A,B,D,F
Rationale: CRF affects fluid/electrolyte balance (impaired excretion), hematologic regulation (anemia from low erythropoietin), metabolism (altered drug clearance), and nutrition (dietary restrictions). Digestion and mobility are less directly impacted.
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.
The male client diagnosed with metastatic cancer of the bladder is emaciated and refuses to eat. Which nursing action is an example of the ethical principle of paternalism?
- A. The nurse allows the client to talk about not wanting to eat.
- B. The nurse tells the client if he does not eat, a feeding tube will be placed.
- C. The nurse consults the dietitian about the client’s nutritional needs.
- D. The nurse asks the family to bring favorite foods for the client to eat.
Correct Answer: B
Rationale: Paternalism involves acting in the client’s best interest without their consent. Threatening a feeding tube overrides the client’s refusal to eat. Allowing discussion, consulting a dietitian, or involving family respect autonomy.
If this client shares cultural characteristics of other Native Americans, which findings in the cultural assessment should be included in the client's care plan? Select all that apply.
- A. Native Americans may hesitate to share personal information with strangers.
- B. Questions regarding health history may be interpreted as prying.
- C. Native Americans value listening skills.
- D. Touching on the head is considered offensive.
- E. Native Americans pattern their lifestyle according to 'clock time.'
- F. Direct eye contact should be used when addressing the client or family.
Correct Answer: A,B,C
Rationale: These cultural characteristics reflect common Native American values and should guide culturally sensitive care.