Nokea
The nurse and an unlicensed assistive personnel (UAP) are caring for clients on a medical floor. Which nursing task is most appropriate for the nurse to delegate?
- A. Collect a clean voided midstream urine specimen.
- B. Evaluate the client’s eight (8)-hour intake and output.
- C. Assist in checking a unit of blood prior to hanging.
- D. Administer a cation-exchange resin enema.
Correct Answer: A
Rationale: Collecting a clean voided midstream urine specimen is a task within the UAP’s scope, as it involves following a standard procedure. Evaluating intake/output, checking blood, or administering enemas require nursing judgment or specialized training, making them inappropriate for delegation.
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The client is in the intensive care department (ICD) after a motor-vehicle accident in which the client lost an estimated three (3) units of blood. Which action by the nurse could prevent the client from developing acute renal failure?
- A. Take and document the client’s vital signs every hour.
- B. Assess the client’s dressings every two (2) hours.
- C. Check the client’s urinary output every shift.
- D. Maintain the client’s blood pressure greater than 100/60.
Correct Answer: D
Rationale: Significant blood loss risks prerenal ARF due to hypoperfusion. Maintaining BP above 100/60 ensures adequate renal perfusion. Vital signs, dressing checks, and urine output monitoring are supportive but less preventive.
The client with CKD is placed on a fluid restriction of 1,500 mL/day. On the 7 a.m. to 7 p.m. shift the client drank an eight (8)-ounce cup of coffee, 4 ounces of juice, 12 ounces of tea, and 2 ounces of water with medications. What amount of fluid can the 7 p.m. to 7 a.m. nurse give to the client?
Correct Answer: 720 mL
Rationale: Convert ounces to mL (1 oz ≈ 30 mL): Coffee: 8 oz = 240 mL, Juice: 4 oz = 120 mL, Tea: 12 oz = 360 mL, Water: 2 oz = 60 mL. Total consumed: 240 + 120 + 360 + 60 = 780 mL. Daily limit: 1,500 mL. Remaining: 1,500 - 780 = 720 mL.
The client diagnosed with ARF has a serum potassium level of 6.8 mEq/L. Which collaborative treatment should the nurse anticipate for the client?
- A. Administer a phosphate binder.
- B. Type and crossmatch for whole blood.
- C. Assess the client for leg cramps.
- D. Prepare the client for dialysis.
Correct Answer: D
Rationale: A potassium level of 6.8 mEq/L indicates severe hyperkalemia, which can cause cardiac arrhythmias. Dialysis is the most effective treatment to rapidly lower potassium in ARF. Phosphate binders, blood transfusions, or assessing cramps do not address hyperkalemia directly.
If this client's condition is similar to that of others in the oliguric phase of renal failure, the nurse would anticipate the client's urine output to be within what range?
- A. 50 to 100 mL/hour
- B. 100 to 150 mL/hour
- C. 500 to 1,000 mL/day
- D. 100 to 500 mL/day
Correct Answer: D
Rationale: The oliguric phase of renal failure is characterized by a urine output of 100–500 mL/day, reflecting significantly reduced kidney function.
Which information should the nurse include when explaining the management of the client's urolithiasis? Select all that apply.
- A. Increase fluid intake to 3 liters per day.
- B. Strain all urine to collect stones for analysis.
- C. Take prescribed analgesics for pain relief.
- D. Avoid all dairy products to prevent stone formation.
- E. Follow a low-sodium diet to reduce stone risk.
- F. Report fever or chills immediately.
Correct Answer: A,B,C,F
Rationale: Increasing fluid intake, straining urine, taking analgesics, and reporting fever or chills are key management strategies for urolithiasis to promote stone passage and prevent complications.