Nokea
The nurse and an unlicensed assistive personnel (UAP) are caring for a group of clients. Which nursing intervention should the nurse perform?
- A. Measure the client’s output from the indwelling catheter.
- B. Record the client’s intake and output on the I&O sheet.
- C. Instruct the client on appropriate fluid restrictions.
- D. Provide water for a client diagnosed with diabetes insipidus.
Correct Answer: C
Rationale: Instructing on fluid restrictions requires nursing judgment and education skills, which are outside the UAP’s scope. Measuring output, recording I&O, and providing water are delegable tasks.
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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.
Which problem is the nurse's immediate concern after kidney transplant surgery?
- A. Risk for infection
- B. Fluid overload
- C. Hypotension
- D. Pain management
Correct Answer: A
Rationale: Risk for infection is the immediate concern post-transplant due to immunosuppression, which increases susceptibility to infections.
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 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.
Which assessment before and after peritoneal dialysis is most valuable in evaluating the outcome of treatment?
- A. Pulse rate
- B. Body weight
- C. A Abdominal girth
- D. Urine output
Correct Answer: B
Rationale: Body weight is the most valuable assessment, as weight loss after dialysis indicates effective removal of excess fluid.