Nokea
The nurse in the dialysis center is initiating the morning dialysis run. Which client should the nurse assess first?
- A. The client who has hemoglobin of 9.8 g/dL and hematocrit of 30%.
- B. The client who does not have a palpable thrill or auscultated bruit.
- C. The client who is complaining of being exhausted and is sleeping.
- D. The client who did not take antihypertensive medication this morning.
Correct Answer: B
Rationale: Absence of a thrill or bruit indicates a non-functioning dialysis access (e.g., AV fistula), which is critical for dialysis and requires immediate assessment to prevent treatment delays or complications. Anemia, exhaustion, or missed medication are less urgent.
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Which information indicates to the nurse the client teaching about treatment of urinary incontinence has been effective?
- A. The client prepares a scheduled voiding plan.
- B. The client verbalizes the need to increase fluid intake.
- C. The client explains how to perform pelvic floor exercises.
- D. The client attempts to retain the vaginal cone in place the entire day.
Correct Answer: C
Rationale: Pelvic floor (Kegel) exercises strengthen muscles to reduce incontinence, indicating effective teaching. Scheduled voiding is a strategy, increased fluids may worsen incontinence, and vaginal cones are not used all day.
The client diagnosed with renal calculi is admitted to the medical unit. Which intervention should the nurse implement first?
- A. Monitor the client’s urinary output.
- B. Assess the client’s pain and rule out complications.
- C. Increase the client’s oral fluid intake.
- D. Use a safety gait belt when ambulating the client.
Correct Answer: B
Rationale: Severe pain is a hallmark of renal calculi, and complications like obstruction or infection must be ruled out first. Pain assessment guides treatment. Monitoring output, increasing fluids, and using a gait belt are secondary.
The telemetry monitor technician notifies the nurse of the morning telemetry readings. Which client should the nurse assess first?
- A. The client in normal sinus rhythm with a peaked T wave.
- B. The client diagnosed with atrial fibrillation with a rate of 100.
- C. The client diagnosed with a myocardial infarction who has occasional PVCs.
- D. The client with a first-degree atrioventricular block and a rate of 92.
Correct Answer: A
Rationale: Peaked T waves indicate hyperkalemia, which can lead to life-threatening arrhythmias, requiring immediate assessment. Atrial fibrillation, PVCs, and first-degree AV block are less urgent unless unstable.
As the nurse instructs the client about CBI, which information should the nurse provide? Select all that apply.
- A. You may feel the urge to urinate even though the bladder is empty.
- B. Do not to try to urinate around the catheter, because this will cause bladder spasms.
- C. You need to limit your fluids to 4 glasses per day.
- D. It is normal for the urine to be bloody immediately after surgery.
- E. The catheter will be removed in about a week.
- F. By the time you are ready to go home, your urine should be pink with a few clots.
Correct Answer: A,B,D,F
Rationale: These statements accurately describe CBI effects, expectations, and precautions post-TURP.
The nurse is caring for a client with chronic pyelonephritis. Which assessment data support the diagnosis of chronic pyelonephritis?
- A. The client has fever, chills, flank pain, and dysuria.
- B. The client complains of fatigue, headaches, and increased urination.
- C. The client had a group B beta-hemolytic strep infection last week.
- D. The client has an acute viral pneumonia infection.
Correct Answer: B
Rationale: Chronic pyelonephritis presents with subtle symptoms like fatigue, headaches, and polyuria due to long-term renal damage. Acute symptoms (fever, chills) are more typical of acute pyelonephritis. Strep or pneumonia are unrelated.