Nokea
The client receiving dialysis is complaining of being dizzy and light-headed. Which action should the nurse implement first?
- A. Place the client in the Trendelenburg position.
- B. Turn off the dialysis machine immediately.
- C. Bolus the client with 500 mL of normal saline.
- D. Notify the health-care provider as soon as possible.
Correct Answer: B
Rationale: Dizziness and light-headedness during dialysis suggest hypotension, often due to rapid fluid removal. Turning off the dialysis machine stops fluid removal, stabilizing the client. Trendelenburg, saline bolus, or notifying the provider are secondary actions.
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The elderly client presents to the emergency department complaining of burning on urination with an urgency to void, and a temperature of 99.8°F. Which intervention should the nurse implement first?
- A. Ask the client to provide a clean voided midstream urine for culture.
- B. Insert an 18-gauge peripheral IV catheter and start normal saline fluids.
- C. Arrange for the client to be admitted to the medical unit.
- D. Initiate the ordered intravenous antibiotic medication.
Correct Answer: A
Rationale: Burning, urgency, and low-grade fever suggest a UTI. A midstream urine culture is the first step to confirm the diagnosis and guide treatment. IV fluids, admission, or antibiotics follow after diagnostic confirmation.
If this client's condition is similar to that of others in the oliguric phase of renal failure, the nurse would anticipate the client's urine output to be within what range?
- A. 50 to 100 mL/hour
- B. 100 to 150 mL/hour
- C. 500 to 1,000 mL/day
- D. 100 to 500 mL/day
Correct Answer: D
Rationale: The oliguric phase of renal failure is characterized by a urine output of 100–500 mL/day, reflecting significantly reduced kidney function.
Which nursing intervention is most appropriate when the nurse is changing the appliance of the client's ileal conduit?
- A. When you remove the appliance, let the urine drip into a container.
- B. When you remove the appliance, insert a tampon into the stoma.
- C. When you remove the appliance, press a gloved finger over the stoma.
- D. When you remove the appliance, pinch the stoma with two fingers.
Correct Answer: C
Rationale: Pressing a gloved finger over the stoma prevents urine leakage during appliance changes, maintaining hygiene and skin integrity.
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.
Which statements should be included when the nurse instructs a female client about the technique for collecting a clean-catch midstream urine specimen for routine urinalysis? Select all that apply.
- A. Clean the urethral area using several circular motions.
- B. Void into the plastic liner under the toilet seat.
- C. Void a small amount, and then collect a sample of urine.
- D. Mix the antiseptic solution with the collected urine specimen.
- E. Collect the urine in the nonsterile cup.
- F. Drink several caffeinated beverages before collecting the urine.
Correct Answer: A,C
Rationale: Cleaning the urethral area and voiding a small amount before collecting the sample ensure a clean-catch specimen, reducing contamination and ensuring accurate results.