Nokea
The elderly client is diagnosed with chronic glomerulonephritis. Which laboratory value indicates to the nurse the condition has become worse?
- A. The blood urea nitrogen is 15 mg/dL.
- B. The creatinine level is 1.2 mg/dL.
- C. The glomerular filtration rate is 40 mL/min.
- D. The 24-hour creatinine clearance is 100 mL/min.
Correct Answer: C
Rationale: A GFR of 40 mL/min indicates significant renal impairment, suggesting worsening chronic glomerulonephritis. Normal BUN (15 mg/dL), creatinine (1.2 mg/dL), and creatinine clearance (100 mL/min) do not reflect deterioration.
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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.
The client returned from surgery after having a TURP and has a P 110, R 24, BP 90/40, and cool and clammy skin. Which interventions should the nurse implement? Select all that apply.
- A. Assess the urine in the continuous irrigation drainage bag.
- B. Decrease the irrigation fluid in the continuous irrigation catheter.
- C. Lower the head of the bed while raising the foot of the bed.
- D. Contact the surgeon to give an update on the client’s condition.
- E. Check the client’s postoperative creatinine and BUN.
Correct Answer: A,C,D
Rationale: Tachycardia, hypotension, and clammy skin suggest hypovolemic shock, likely from bleeding. Assess urine for blood, use Trendelenburg to improve perfusion, and notify the surgeon. Decreasing irrigation may worsen clotting, and lab checks are less urgent.
The client diagnosed with renal calculi is scheduled for lithotripsy. Which postprocedure nursing task is the most appropriate to delegate to the UAP?
- A. Monitor the amount, color, and consistency of urine output.
- B. Teach the client about care of the indwelling Foley catheter.
- C. Assist the client to the car when being discharged home.
- D. Take the client’s postprocedural vital signs.
Correct Answer: C
Rationale: Assisting the client to the car is a non-clinical task within the UAP’s scope. Monitoring urine, teaching catheter care, and taking vital signs require nursing judgment and are not delegable.
Which data support to the nurse the client’s diagnosis of acute bacterial prostatitis?
- A. Terminal dribbling.
- B. Urinary frequency.
- C. Stress incontinence.
- D. Sudden fever and chills.
Correct Answer: D
Rationale: Acute bacterial prostatitis presents with sudden systemic symptoms like fever and chills, often with dysuria. Terminal dribbling, frequency, and incontinence are more typical of BPH or chronic conditions.
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.