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The nurse is admitting a client diagnosed with acute renal failure (ARF). Which question is most important for the nurse to ask during the admission interview?
- A. Have you recently traveled outside the United States?
- B. Did you recently begin a vigorous exercise program?
- C. Is there a chance you have been exposed to a virus?
- D. What over-the-counter medications do you take regularly?
Correct Answer: D
Rationale: Acute renal failure can be caused by nephrotoxic agents, including over-the-counter medications like NSAIDs. Asking about medication use identifies potential causes of ARF, which is more directly relevant than travel, exercise, or viral exposure.
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The client diagnosed with a fluid and electrolyte disturbance in the emergency department is exhibiting peaked T waves on the STAT electrocardiogram. Which interventions should the nurse implement? List in order of priority.
- A. Assess the client for leg and muscle cramps.
- B. Check the serum potassium level.
- C. Notify the health-care provider.
- D. Arrange for a transfer to the telemetry floor.
- E. Administer Kayexalate, a cation resin.
Correct Answer: B,C,E,D,A
Rationale: Peaked T waves indicate hyperkalemia. Priority: 1) Check potassium level to confirm; 2) Notify HCP for orders; 3) Administer Kayexalate to lower potassium; 4) Transfer to telemetry for monitoring; 5) Assess cramps, a less urgent symptom.
Which nursing diagnosis is priority for the client who has undergone a TURP?
- A. Potential for sexual dysfunction.
- B. Potential for an altered body image.
- C. Potential for chronic infection.
- D. Potential for hemorrhage.
Correct Answer: D
Rationale: Hemorrhage is the priority post-TURP due to the risk of significant bleeding from the surgical site, which can be life-threatening. Sexual dysfunction, body image, and infection are secondary concerns.
When preparing the client for catheterization, how should the nurse position the client?
- A. Lithotomy position
- B. Recumbent
- C. Knee-chest position
- D. Prone
Correct Answer: A
Rationale: The lithotomy position provides optimal access to the urethral meatus for catheterization in female clients.
The laboratory data reveal a calcium phosphate renal stone for a client diagnosed with renal calculi. Which discharge teaching intervention should the nurse implement?
- A. Encourage the client to eat a low-purine diet and limit foods such as organ meats.
- B. Explain the importance of not drinking water two (2) hours before bedtime.
- C. Discuss the importance of limiting vitamin D-enriched foods.
- D. Prepare the client for extracorporeal shock wave lithotripsy (ESWL).
Correct Answer: C
Rationale: Calcium phosphate stones are linked to hypercalciuria. Limiting vitamin D-enriched foods reduces calcium absorption, preventing recurrence. Low-purine diets are for uric acid stones, water restriction is contraindicated, and ESWL is a treatment, not teaching.
When the nurse inspects the client's urine specimen, which finding best indicates that the urine contains red blood cells?
- A. The urine appears cloudy.
- B. The urine appears smoky.
- C. The urine appears bright orange.
- D. The urine appears dark yellow.
Correct Answer: B
Rationale: Smoky urine is indicative of hematuria (red blood cells in the urine), a common finding in glomerulonephritis due to kidney inflammation.