Nokea
The client is in the intensive care department (ICD) after a motor-vehicle accident in which the client lost an estimated three (3) units of blood. Which action by the nurse could prevent the client from developing acute renal failure?
- A. Take and document the client’s vital signs every hour.
- B. Assess the client’s dressings every two (2) hours.
- C. Check the client’s urinary output every shift.
- D. Maintain the client’s blood pressure greater than 100/60.
Correct Answer: D
Rationale: Significant blood loss risks prerenal ARF due to hypoperfusion. Maintaining BP above 100/60 ensures adequate renal perfusion. Vital signs, dressing checks, and urine output monitoring are supportive but less preventive.
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When documenting the client's urine output in the medical record, which measurement is correct for the nurse to record?
- A. Only the output from the urethral catheter
- B. Only the output from the wound catheter
- C. The outputs from each catheter separately
- D. The combined output from both catheters
Correct Answer: D
Rationale: The combined output from both catheters provides the total urine output, which is essential for accurate monitoring.
The client from a long-term care facility is admitted to the medical unit with a fever, hot flushed skin, and clumps of white sediment in the indwelling catheter. Which intervention should the nurse implement first?
- A. Start an IV with a 20-gauge catheter.
- B. Initiate antibiotic therapy IVPB.
- C. Collect a urine specimen for culture.
- D. Change the indwelling catheter.
Correct Answer: C
Rationale: Symptoms suggest a catheter-associated UTI. Collecting a urine culture first identifies the causative organism, guiding antibiotic therapy. Starting an IV, antibiotics, or changing the catheter are secondary to obtaining a diagnostic sample.
Which information should the nurse include when explaining the management of the client's urolithiasis? Select all that apply.
- A. Increase fluid intake to 3 liters per day.
- B. Strain all urine to collect stones for analysis.
- C. Take prescribed analgesics for pain relief.
- D. Avoid all dairy products to prevent stone formation.
- E. Follow a low-sodium diet to reduce stone risk.
- F. Report fever or chills immediately.
Correct Answer: A,B,C,F
Rationale: Increasing fluid intake, straining urine, taking analgesics, and reporting fever or chills are key management strategies for urolithiasis to promote stone passage and prevent complications.
The nurse is caring for clients on a renal surgery unit. After the afternoon report, which client should the nurse assess first?
- A. The male client who just returned from a CT scan who states he left his glasses in the x-ray department.
- B. The client who is one (1) day postoperative and has a moderate amount of serous drainage on the dressing.
- C. The client who is scheduled for surgery in the morning and wants an explanation of the operative procedure before signing the permit.
- D. The client who had ileal conduit surgery this morning and has not had any drainage in the drainage bag.
Correct Answer: D
Rationale: No drainage in the ileal conduit bag post-surgery suggests obstruction or complications, risking urine backup and renal damage. This is critical. Lost glasses, serous drainage, and surgical education are less urgent.
Which intervention is most important for the nurse to implement for the client diagnosed with rule-out renal calculi?
- A. Assess the client’s neurological status every two (2) hours.
- B. Strain all urine and send any sediment to the laboratory.
- C. Monitor the client’s creatinine and BUN levels.
- D. Take a 24-hour dietary recall during the client interview.
Correct Answer: B
Rationale: Straining urine to capture stones or sediment is critical for diagnosing renal calculi, as it confirms the presence and type of stones. Neurological status, lab monitoring, and dietary recall are secondary.