Nokea
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.
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The nurse is caring for a client diagnosed with rule-out ARF. Which condition predisposes the client to developing prerenal failure?
- A. Diabetes mellitus.
- B. Hypotension.
- C. Aminoglycosides.
- D. Benign prostatic hypertrophy.
Correct Answer: B
Rationale: Prerenal failure results from decreased renal perfusion. Hypotension reduces blood flow to the kidneys, directly causing prerenal ARF. Diabetes and aminoglycosides contribute to intrinsic renal damage, while BPH causes postrenal issues.
The client diagnosed with diabetes insipidus weighed 180 pounds when the daily weight was taken yesterday. This morning’s weight is 175.6 pounds. One liter of fluid weighs approximately 2.2 pounds. How much fluid has the client lost?
Correct Answer: 2 L
Rationale: Weight loss: 180 - 175.6 = 4.4 pounds. Fluid loss: 4.4 pounds ÷ 2.2 pounds/L = 2 L. This calculation accounts for fluid loss typical in diabetes insipidus due to excessive urination.
Which client should the nurse not assign to a UAP working on a surgical floor?
- A. The client with a suprapubic catheter inserted yesterday.
- B. The client who has had an indwelling catheter for the past week.
- C. The client who is on a bladder-training regimen.
- D. The client who had a catheter removed this morning and is being discharged.
Correct Answer: C
Rationale: A client on a bladder-training regimen requires nursing judgment to assess progress and adjust the plan, which is outside the UAP’s scope. Routine catheter care or post-removal care can be assigned.
The UAP tells the nurse the client with ARF has a white crystal-like layer on top of the skin. Which intervention should the nurse implement?
- A. Have the assistant apply a moisture barrier cream to the skin.
- B. Instruct the UAP to bathe the client in cool water.
- C. Tell the UAP not to turn the client in this condition.
- D. Explain this is normal and do not do anything for the client.
Correct Answer: D
Rationale: The white crystal-like layer is uremic frost, a result of urea crystallizing on the skin due to severe uremia in ARF. This is an expected finding and requires no specific intervention beyond routine skin care and dialysis to address uremia.
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.