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The nurse is assessing the urine of a client who has had an ileal conduit and notes that the urine is yellow with a moderate amount of mucus. Based on the data, the nurse should?
- A. Change the appliance bag.
- B. Notify the physician.
- C. Obtain a urine specimen for culture.
- D. Encourage a high fluid intake.
Correct Answer: D
Rationale: Yellow urine with moderate mucus is normal for an ileal conduit due to intestinal segment use. Encouraging high fluid intake prevents complications like calculi or infection.
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The client with a spinal cord injury asks the nurse why the dietitian has recommended to decrease the total daily intake of calcium. Which of the following responses by the nurse would provide the most accurate information?
- A. Excessive intake of dairy products makes constipation more common.'
- B. Immobility increases calcium absorption from the intestine.'
- C. Lack of weight bearing causes demineralization of the long bones.'
- D. Dairy products likely will contribute to weight gain.'
Correct Answer: C
Rationale: Immobility leads to bone demineralization, increasing calcium release and risk of hypercalcemia.
A client with acute renal failure has a low calcium level. The nurse should monitor for:
- A. Tetany.
- B. Hypertension.
- C. Bradycardia.
- D. Edema.
Correct Answer: A
Rationale: Low calcium can cause tetany, manifesting as muscle cramps or spasms.
The nurse assesses vital signs on a client who has had epidural anesthesia. For which of the following should the nurse assess next?
- A. Bladder distention.
- B. Headache.
- C. Postoperative pain.
- D. Ability to move the legs.
Correct Answer: A
Rationale: Epidural anesthesia can cause urinary retention due to sensory and motor nerve blockade. Assessing for bladder distention is critical to prevent complications like bladder overdistension.
A client has a positive reaction to the Mantoux test. The nurse correctly interprets this reaction to mean that the client has:
- A. Active tuberculosis.
- B. Had contact with Mycobacterium tuberculosis.
- C. Developed a resistance to tubercle bacilli.
- D. Developed passive immunity to tuberculosis.
Correct Answer: B
Rationale: A positive Mantoux test indicates exposure to Mycobacterium tuberculosis, not necessarily active disease. It does not imply resistance or passive immunity.
The client tells the nurse that since his diagnosis of stomach cancer, he has been having trouble sleeping and is frequently preoccupied with thoughts about how his life will change. He says, 'I wish my life could stay the same.' Based on this information, which one of the following nursing diagnoses would be appropriate at this time?
- A. Ineffective coping related to the diagnosis of cancer.
- B. Insomnia related to fear of the unknown.
- C. Grieving related to the diagnosis of cancer.
- D. Anxiety related to the need for gastric surgery.
Correct Answer: C
Rationale: The client's statement and symptoms suggest grieving related to the life-altering diagnosis of stomach cancer. This diagnosis best captures the emotional response to the anticipated changes.