Nokea
The nurse is assessing a client diagnosed with urethral strictures. Which data support the diagnosis?
- A. Complaints of frequency and urgency.
- B. Clear yellow drainage from the urethra.
- C. Complaints of burning during urination.
- D. A diminished force and stream during voiding.
Correct Answer: D
Rationale: Urethral strictures obstruct urine flow, causing a diminished force and stream. Frequency, urgency, and burning suggest UTI, and clear drainage is unrelated.
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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.
Considering the amount of time the client must remain in bed, why is it imperative for the nurse to monitor for a urinary tract infection?
- A. The client will not be able to complete hygiene needs.
- B. The client will not be able to fully empty the bladder.
- C. The client will not be able to maintain bladder control.
- D. The client will not be able to drink sufficient fluids.
Correct Answer: B
Rationale: Prolonged bed rest can lead to incomplete bladder emptying, increasing the risk of urinary stasis and subsequent urinary tract infections.
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.
Immediately after the dialysate solution has been instilled, which nursing action is correct?
- A. Clamping the tubing from the infusion
- B. Draining the infused dialysate solution
- C. Restricting the client's movement as much as possible
- D. Encouraging the client to drink fluids
Correct Answer: A
Rationale: Clamping the tubing after instillation allows the dialysate to dwell, facilitating the exchange of waste products.
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.