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The elderly client being seen in the clinic has complaints of urinary frequency, urgency, and 'leaking.' Which priority intervention should the nurse implement when interviewing the client?
- A. Ensure communication is nonjudgmental and respectful.
- B. Set the temperature for comfort in the examination room.
- C. Speak loudly to ensure the client understands the nurse.
- D. Ensure the examining room has adequate lighting.
Correct Answer: A
Rationale: Nonjudgmental, respectful communication builds trust, encouraging the elderly client to discuss sensitive incontinence issues openly. Comfort, loud speech, and lighting are secondary to effective communication.
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Which outcome should the nurse identify for the client diagnosed with fluid volume excess?
- A. The client will void a minimum of 30 mL per hour.
- B. The client will have elastic skin turgor.
- C. The client will have no adventitious breath sounds.
- D. The client will have a serum creatinine of 1.4 mg/dL.
Correct Answer: C
Rationale: No adventitious breath sounds (e.g., crackles) indicates resolution of pulmonary edema from fluid volume excess. Adequate urine output and elastic skin turgor are normal but not specific, and creatinine reflects renal function, not fluid status.
The client receiving hemodialysis is being discharged home from the dialysis center. Which instruction should the nurse teach the client?
- A. Notify the HCP if oral temperature is 102°F or greater.
- B. Apply ice to the access site if it starts bleeding at home.
- C. Keep fingernails short and try not to scratch the skin.
- D. Encourage the significant other to make decisions for the client.
Correct Answer: A
Rationale: A fever of 102°F or higher may indicate infection, a serious complication in hemodialysis patients, requiring prompt HCP notification. Ice may worsen bleeding, short nails are general advice, and encouraging dependency is not therapeutic.
When the nurse interviews the client, which symptoms will the client most likely report if a bladder infection has been acquired? Select all that apply.
- A. Sharp flank pain
- B. Uretrail discharge
- C. Strong-smelling urine
- D. Burning on urination
- E. Urgency
- F. Frequency
Correct Answer: C,D,E,F
Rationale: Symptoms of a bladder infection typically include strong-smelling urine, burning on urination, urgency, and frequency, as these reflect irritation and inflammation of the bladder.
When the client complains about the bland taste of the food, the nurse appropriately recommends substituting salt with which condiment?
- A. Catsup
- B. Mustard
- C. Soy sauce
- D. Lemon juice
Correct Answer: D
Rationale: Lemon juice is a low-sodium flavor enhancer, suitable for a sodium-restricted diet, unlike catsup, mustard, or soy sauce.
The nurse is caring for an elderly client who has an indwelling catheter. Which data warrant further investigation?
- A. The client’s temperature is 98°F.
- B. The client has become confused and irritable.
- C. The client’s urine is clear and light yellow.
- D. The client feels the need to urinate.
Correct Answer: B
Rationale: New-onset confusion and irritability in an elderly client with a catheter suggest a possible UTI, requiring investigation. Normal temperature, clear urine, and urge sensation are expected or less concerning.