Nokea
The client with a continent urinary diversion is being discharged. Which discharge instructions should the nurse include in the teaching?
- A. Have the client demonstrate catheterizing the stoma.
- B. Instruct the client on how to pouch the stoma.
- C. Explain the use of a bedside drainage bag at night.
- D. Tell the client to call the HCP if the temperature is 99°F or less.
Correct Answer: A
Rationale: A continent urinary diversion (e.g., Indiana pouch) requires periodic catheterization of the stoma. Demonstrating this ensures the client can manage it. Pouching and drainage bags are for incontinent diversions, and a 99°F fever is not concerning.
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The nurse emptied 2,000 mL from the drainage bag of a continuous irrigation of a client who had a transurethral resection of the prostate (TURP). The amount of irrigation in the bag hanging was 3,000 mL at the beginning of the shift. There was 1,800 mL left in the bag eight (8) hours later. What is the correct urine output at the end of the eight (8) hours?
Correct Answer: 800 mL
Rationale: Irrigation used: 3,000 mL - 1,800 mL = 1,200 mL. Total drainage: 2,000 mL. Urine output: 2,000 mL - 1,200 mL = 800 mL. This isolates actual urine from irrigation fluid.
Which comment is the best response the nurse can offer?
- A. You're a very nice person.
- B. You're a very nice person.
- C. You should expect this at your age.
- D. You're discouraged right now.
Correct Answer: D
Rationale: Acknowledging the client's feelings of discouragement validates their emotional state and opens the door for supportive communication.
The client is admitted with a serum sodium level of 110 mEq/L. Which nursing intervention should be implemented?
- A. Encourage fluids orally.
- B. Administer 10% saline solution IVPB.
- C. Administer antidiuretic hormone intranasally.
- D. Place on seizure precautions.
Correct Answer: D
Rationale: Severe hyponatremia (110 mEq/L) increases seizure risk due to cerebral edema. Seizure precautions are the priority to ensure safety. Oral fluids or ADH may worsen hyponatremia, and 10% saline is not standard.
The nurse is preparing the plan of care for the client diagnosed with a neurogenic flaccid bladder. Which expected outcome is appropriate for this client?
- A. The client has conscious control over bladder activity.
- B. The client’s bladder does not become overdistended.
- C. The client has bladder sensation and no discomfort.
- D. The client demonstrates how to check for bladder distention.
Correct Answer: B
Rationale: A neurogenic flaccid bladder lacks tone, risking overdistention. Preventing this is a key outcome to avoid complications like infection or reflux. Conscious control and sensation are unlikely, and checking distention is an intervention.
The client with CKD is placed on a fluid restriction of 1,500 mL/day. On the 7 a.m. to 7 p.m. shift the client drank an eight (8)-ounce cup of coffee, 4 ounces of juice, 12 ounces of tea, and 2 ounces of water with medications. What amount of fluid can the 7 p.m. to 7 a.m. nurse give to the client?
Correct Answer: 720 mL
Rationale: Convert ounces to mL (1 oz ≈ 30 mL): Coffee: 8 oz = 240 mL, Juice: 4 oz = 120 mL, Tea: 12 oz = 360 mL, Water: 2 oz = 60 mL. Total consumed: 240 + 120 + 360 + 60 = 780 mL. Daily limit: 1,500 mL. Remaining: 1,500 - 780 = 720 mL.