Nokea
The nurse caring for a client diagnosed with CKD writes a client problem of 'noncompliance with dietary restrictions.' Which intervention should be included in the plan of care?
- A. Teach the client the proper diet to eat while undergoing dialysis.
- B. Refer the client and significant other to the dietitian.
- C. Explain the importance of eating the proper foods.
- D. Determine the reason for the client not adhering to the diet.
Correct Answer: D
Rationale: Determining the reason for noncompliance (e.g., lack of understanding, financial barriers) is the first step to tailor interventions effectively. Teaching, referrals, or explaining importance are secondary until the root cause is identified.
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The client is admitted to the emergency department after a gunshot wound to the abdomen. Which nursing intervention should the nurse implement first to prevent ARF?
- A. Administer normal saline IV.
- B. Take vital signs.
- C. Place client on telemetry.
- D. Assess abdominal dressing.
Correct Answer: A
Rationale: A gunshot wound can cause hypovolemia, leading to prerenal ARF. Administering normal saline IV restores volume and perfusion, preventing ARF. Vital signs, telemetry, and dressing assessment are important but secondary to fluid resuscitation.
When the nurse mistakenly inserts the catheter into the client's vagina rather than the urinary meatus, which action is best to take next?
- A. Wipe the catheter tip with an alcohol swab.
- B. Clean the catheter tip with povidone-iodine solution (Betadine).
- C. Discard the catheter and use another sterile one.
- D. Withdraw the catheter and insert it in the urethra.
Correct Answer: C
Rationale: Inserting the catheter into the vagina contaminates it, so a new sterile catheter must be used to prevent infection.
Which of the following findings is the most significant information to report when caring for a client undergoing peritoneal dialysis?
- A. Loss of body weight
- B. Decreased serum creatinine
- C. Elevated body temperature
- D. Output that exceeds intake
Correct Answer: C
Rationale: An elevated body temperature may indicate infection, a serious complication of peritoneal dialysis, and must be reported.
When the client with an ileal conduit expresses concern about odor, which recommendation by the nurse is most effective?
- A. Place an aspirin tablet in the pouch.
- B. Use a deodorizing pouch spray.
- C. Change the pouch daily.
- D. Avoid acidic foods.
Correct Answer: B
Rationale: Using a deodorizing pouch spray effectively controls odor, addressing the client's concern.
Postoperatively, which assessment finding is most suggestive that the client is hemorrhaging?
- A. Acute flank pain
- B. Abdominal distention
- C. Flushed, warm skin
- D. Nausea and vomiting
Correct Answer: B
Rationale: Abdominal distention may indicate internal bleeding, a critical sign of hemorrhage post-nephrectomy.