Nokea
The client is admitted to the emergency department after a gunshot wound to the abdomen. Which nursing intervention should the nurse implement first to prevent ARF?
- A. Administer normal saline IV.
- B. Take vital signs.
- C. Place client on telemetry.
- D. Assess abdominal dressing.
Correct Answer: A
Rationale: A gunshot wound can cause hypovolemia, leading to prerenal ARF. Administering normal saline IV restores volume and perfusion, preventing ARF. Vital signs, telemetry, and dressing assessment are important but secondary to fluid resuscitation.
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Which intervention should the nurse implement for the client who has had an ileal conduit?
- A. Pouch the stoma with a one (1)-inch margin around the stoma.
- B. Refer the client to the United Ostomy Association for discharge teaching.
- C. Report to the health-care provider any decrease in urinary output.
- D. Monitor the stoma for signs and symptoms of infection every shift.
Correct Answer: D
Rationale: Monitoring the stoma for infection (e.g., redness, discharge) prevents complications. Pouching requires a precise fit, not a 1-inch margin; ostomy referrals are secondary; and decreased output is monitored but not always reported immediately.
Which nursing intervention is most important to add to the client's care plan after removal of the suprapubic catheter?
- A. Check the client's urine specific gravity every shift.
- B. Measure the client's abdominal girth daily.
- C. Change wet abdominal dressings as needed.
- D. Perform a credé maneuver every 4 hours.
Correct Answer: C
Rationale: Changing wet dressings prevents infection and promotes healing at the suprapubic site.
The nurse is providing discharge teaching to the client diagnosed with polycystic kidney disease. Which statement made by the client indicates the teaching has been effective?
- A. I need to avoid any activity causing a risk for injury to my kidney.'
- B. I should avoid taking medications for high blood pressure.'
- C. When I urinate there may be blood streaks in my urine.'
- D. I may have occasional burning when I urinate with this disease.'
Correct Answer: A
Rationale: Polycystic kidney disease causes enlarged, cystic kidneys prone to rupture. Avoiding trauma (e.g., contact sports) is critical. BP meds are necessary, hematuria is not expected, and burning suggests UTI.
The nurse is caring for a client with chronic pyelonephritis. Which assessment data support the diagnosis of chronic pyelonephritis?
- A. The client has fever, chills, flank pain, and dysuria.
- B. The client complains of fatigue, headaches, and increased urination.
- C. The client had a group B beta-hemolytic strep infection last week.
- D. The client has an acute viral pneumonia infection.
Correct Answer: B
Rationale: Chronic pyelonephritis presents with subtle symptoms like fatigue, headaches, and polyuria due to long-term renal damage. Acute symptoms (fever, chills) are more typical of acute pyelonephritis. Strep or pneumonia are unrelated.
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.