Nokea
The client is one (1) day postoperative TURP. Which task should the nurse delegate to the UAP?
- A. Increase the irrigation fluid to clear clots from the tubing.
- B. Elevate the scrotum on a towel roll for support.
- C. Change the dressing on the first postoperative day.
- D. Teach the client how to care for the continuous irrigation catheter.
Correct Answer: B
Rationale: Elevating the scrotum is a simple supportive task within the UAP’s scope. Adjusting irrigation, changing dressings, and teaching require nursing judgment and are not delegable.
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Which of the following measures performed by the client would offer the best protection against acquiring a urinary tract infection?
- A. Wiping away from the urinary meatus after bowel elimination
- B. Performing appropriate hand washing after bowel elimination
- C. Using a feminine hygiene spray after bowel elimination
- D. Drying the perineum thoroughly after bowel elimination
Correct Answer: A
Rationale: Wiping away from the urinary meatus prevents fecal bacteria from being introduced into the urethra, reducing UTI risk.
Which dietary recommendation should the nurse provide to the client to prevent the recurrence of calcium oxalate stones?
- A. Increase intake of leafy green vegetables
- B. Limit intake of oxalate-rich foods
- C. Avoid all protein-rich foods
- D. Decrease fluid intake
Correct Answer: B
Rationale: Limiting oxalate-rich foods (e.g., spinach, nuts) reduces the formation of calcium oxalate stones.
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.
The client is two (2) days postureterosigmoidostomy for cancer of the bladder. Which assessment data warrant notification of the HCP by the nurse?
- A. The client complains of pain at a '3,' 30 minutes after being medicated.
- B. The client complains it hurts to cough and deep breathe.
- C. The client ambulates to the end of the hall and back before lunch.
- D. The client is lying in a fetal position and has a rigid abdomen.
Correct Answer: D
Rationale: A rigid abdomen and fetal position suggest peritonitis or other serious complications (e.g., anastomotic leak) post-ureterosigmoidostomy, requiring immediate HCP notification. Mild pain, coughing discomfort, and ambulation are less urgent.
The client diagnosed with ARF is admitted to the intensive care department and placed on a therapeutic diet. Which diet is most appropriate for the client?
- A. A high-potassium and low-calcium diet.
- B. A low-fat and low-cholesterol diet.
- C. A high-carbohydrate and restricted-protein diet.
- D. A regular diet with six (6) small feedings a day.
Correct Answer: C
Rationale: ARF patients require a restricted-protein diet to reduce urea production and a high-carbohydrate diet to provide energy, minimizing protein catabolism. High-potassium diets are contraindicated due to hyperkalemia risk, and low-fat or regular diets are less specific.