Nokea
The male client diagnosed with CKD has received the initial dose of erythropoietin, a biologic response modifier, one (1) week ago. Which complaint by the client indicates the need to notify the health-care provider?
- A. The client complains of flu-like symptoms.
- B. The client complains of being tired all the time.
- C. The client reports an elevation in his blood pressure.
- D. The client reports discomfort in his legs and back.
Correct Answer: C
Rationale: Erythropoietin can cause hypertension as a side effect, which is significant in CKD patients and warrants notifying the provider. Flu-like symptoms and fatigue are common and expected, while leg/back discomfort is less specific.
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The client had surgery to remove a kidney stone. Which laboratory assessment data warrant immediate intervention by the nurse?
- A. A serum potassium level of 3.8 mEq/L.
- B. A urinalysis shows microscopic hematuria.
- C. A creatinine level of 0.8 mg/100 mL.
- D. A white blood cell count of 14,000/mm3.
Correct Answer: D
Rationale: An elevated WBC (14,000/mm3) suggests infection, a serious post-surgical complication requiring immediate intervention. Normal potassium (3.8 mEq/L), creatinine (0.8 mg/dL), and microscopic hematuria are expected or benign.
Which nursing assessment is essential to add to the client's care plan?
- A. Monitor body temperature.
- B. Measure intake and output.
- C. Assess for urine retention.
- D. Check the urine for glucose.
Correct Answer: B
Rationale: Measuring intake and output is critical in renal failure to monitor fluid balance and kidney function.
Before administering an analgesic to the client, which information is most important for the nurse to assess?
- A. Whether the urine is bloody
- B. Whether the client has been up walking in the room
- C. Whether the catheter is draining urine
- D. Whether the client has been drinking adequate fluids
Correct Answer: C
Rationale: Ensuring the catheter is draining urine is critical to prevent bladder distention, which could exacerbate discomfort.
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 nursing action is most appropriate when the client complains about being thirsty because of the fluid restrictions?
- A. Giving the client hard candy to suck
- B. Providing the client with ice chips
- C. Offering the client an ice cream bar
- D. Supplying the client with fresh fruit
Correct Answer: A
Rationale: Hard candy stimulates saliva production, alleviating thirst without contributing to fluid intake, which is restricted.