Nokea
The elderly client recovering from a prostatectomy has been experiencing stress incontinence. Which independent nursing intervention should the nurse discuss with the client?
- A. Establish a set voiding frequency of every two (2) hours while awake.
- B. Encourage a family member to assist the client to the bathroom to void.
- C. Apply a transurethral electrical stimulator to relieve symptoms of urinary urgency.
- D. Discuss the use of a 'bladder drill,' including a timed voiding schedule.
Correct Answer: D
Rationale: A bladder drill with timed voiding strengthens bladder control and reduces stress incontinence post-prostatectomy. Voiding every 2 hours is part of it, family assistance reduces independence, and electrical stimulators are not standard.
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The nurse writes the client problem of 'fluid volume excess' (FVE). Which intervention should be included in the plan of care?
- A. Change the IV fluid from 0.9% NS to D5W.
- B. Restrict the sodium in the client’s diet.
- C. Monitor blood glucose levels.
- D. Prepare the client for hemodialysis.
Correct Answer: B
Rationale: Restricting sodium reduces fluid retention in FVE, as sodium promotes water reabsorption. D5W provides free water, worsening FVE; glucose monitoring is unrelated; and hemodialysis is reserved for severe cases.
The client diagnosed with ARF is placed on bedrest. The client asks the nurse, 'Why do I have to stay in bed? I don’t feel bad.' Which scientific rationale supports the nurse’s response?
- A. Bedrest helps increase the blood return to the renal circulation.
- B. Bedrest reduces the metabolic rate during the acute stage.
- C. Bedrest decreases the workload of the left side of the heart.
- D. Bedrest aids in reduction of peripheral and sacral edema.
Correct Answer: B
Rationale: Bedrest reduces the body’s metabolic demands, minimizing stress on the kidneys during the acute phase of ARF. It does not directly increase renal blood flow, reduce heart workload, or address edema in this context.
The nurse is developing a nursing care plan for the client diagnosed with CKD. Which nursing problem is priority for the client?
- A. Low self-esteem.
- B. Knowledge deficit.
- C. Activity intolerance.
- D. Excess fluid volume.
Correct Answer: D
Rationale: Excess fluid volume is the priority in CKD due to impaired kidney excretion, leading to edema, hypertension, and heart failure risk. Fluid overload is a life-threatening issue, whereas self-esteem, knowledge, and activity intolerance are secondary.
Which nursing assessment is most important to perform regularly when a client has an arteriovenous fistula?
- A. Checking the color and temperature of the client's hand
- B. Monitoring the client's wrist and finger range of motion
- C. Improving the tone and coordination of the client's arm muscles
- D. Inspecting the client's forearm skin turgor
Correct Answer: A
Rationale: Checking the color and temperature of the hand ensures adequate blood flow and detects complications like thrombosis in the arteriovenous fistula.
Which statements made by a diabetic client at the clinic strongly suggest that the client has a urinary tract infection? Select all that apply.
- A. I need to urinate frequently.
- B. I can't hold my urine.
- C. I have a burning sensation when I urinate.
- D. I have a burning sensation when I urinate.
- E. I pass a large quantity of urine.
- F. My urine is foul-smelling.
Correct Answer: A,B,C,F
Rationale: Frequent urination, inability to hold urine, burning sensation, and foul-smelling urine are classic symptoms of a urinary tract infection.