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The nurse is assigned to care for a client with a sodium level of 122 mEq/L (mmol/L) [135-145 mEq/L, mmol/L]. Which assessment findings does the nurse anticipate based on this lab result?
- A. Confusion
- B. Abdominal cramps
- C. Tall, peaked t-waves
- D. Hypoactive bowel sounds
- E. Nausea and vomiting
Correct Answer: A,B,E
Rationale: Hyponatremia causes confusion, abdominal cramps, and nausea/vomiting due to cerebral edema and gastrointestinal irritation.
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The nurse is caring for a client with urge incontinence. Which of the following actions would be appropriate for the nurse to take?
- A. Administer prophylactic antibiotics.
- B. Teach the client intermittent self-catheterization.
- C. Have the client void on a timed schedule.
- D. Provide caffeinated beverages with meals.
Correct Answer: C
Rationale: Timed voiding helps manage urge incontinence by preventing bladder overfilling, reducing involuntary contractions.
The oncoming nurse learns that her new patient is suffering from Syndrome of Inappropriate Antidiuretic Hormone (SIADH) secretion. Which of the following nursing actions is the most important?
- A. Assess the patient's mental status
- B. Provide oral hygiene
- C. Keep accurate intake and output measurements
- D. Reduce stress and discomfort
Correct Answer: A
Rationale: SIADH causes hyponatremia, which can lead to neurological changes, making mental status assessment critical.
The nurse is providing discharge instructions to a client prescribed phenazopyridine. Which of the following instructions should the nurse include?
- A. Discontinue this medication if urinary discoloration occurs
- B. Take this medication on an empty stomach
- C. This medication may increase the amount of urine you produce
- D. Urine may have a reddish or orange coloration after taking this medication
Correct Answer: D
Rationale: Phenazopyridine commonly causes reddish or orange urine, which is harmless and should be explained to the client. Discontinuing the medication (A) is unnecessary, it can be taken with or without food (B), and it does not increase urine output (C).
The nurse is assessing assigned clients. Which client has a risk for urinary retention? Select all that apply.
- A. A 78-year-old man diagnosed with an enlarged prostate.
- B. An 83-year-old woman on bed rest.
- C. A 75-year-old woman with vaginal prolapse.
- D. An 89-year-old man with dementia.
- E. A 73-year-old woman on antihistamines to treat allergies.
- F. A 90-year-old man with difficulty walking to the restroom.
Correct Answer: A,C,D,E,F
Rationale: Enlarged prostate, vaginal prolapse, dementia, antihistamines, and mobility issues impair bladder emptying, increasing urinary retention risk.
The nurse has taught a client about a scheduled intravenous (IV) urography (pyelogram). Which of the following statements by the client would indicate a correct understanding of the teaching?
- A. I should expect a temporary urinary catheter inserted during the procedure.
- B. I will take a laxative the night before to clear my bowels.
- C. I must fill my bladder with water immediately before the procedure.
- D. I may experience blood in my urine for a few days after this procedure.
Correct Answer: B
Rationale: A laxative is often required before IV urography to clear the bowels for better imaging.