Nokea
The nurse is caring for a 68-year-old individual in the emergency department who had been on the bathroom floor for about 10 hours after a fall. While performing straight catheterization, the nurse notes that the urine output reaches 800 mL and continues to flow heavily. What action should the nurse take, and what is the rationale for this action?
- A. Drain the client's bladder entirely and place a small amount in a urine specimen cup. This client needs a urine sample to check for rhabdomyolysis.
- B. Continue draining the bladder fully, then place a Foley catheter to monitor for sufficient urine output.
- C. Stop draining the client's bladder because the client is at risk for developing bladder spasms.
- D. Stop draining the client's bladder to prevent the risk of urinary tract infection (UTI) and notify the primary healthcare provider (PHCP) for further instructions.
Correct Answer: A
Rationale: Prolonged immobility increases rhabdomyolysis risk, requiring a urine sample to check for myoglobin.
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The nurse is teaching a client with hypercalcemia appropriate dietary measures. Which food selections by the client would require follow-up by the nurse? Select all that apply.
- A. broccoli
- B. 2% milk
- C. whole wheat pasta
- D. bananas
- E. seafood
Correct Answer: B
Rationale: Milk is high in calcium and should be limited in hypercalcemia to prevent worsening the condition.
The nurse is providing education to a group of nursing students regarding the causes of hypercalcemia. Which of the following information should be included? Select all that apply.
- A. hypoparathyroidism.
- B. thiazide diuretics.
- C. malignancy.
- D. end-stage kidney disease.
- E. Crohn's disease.
Correct Answer: B,C,D
Rationale: Thiazide diuretics, malignancy, and end-stage kidney disease cause hypercalcemia by increasing calcium retention or release.
The nurse is assessing a client receiving peritoneal dialysis. Which laboratory result should immediately be reported to the primary healthcare provider (PHCP)?
- A. WBC 19,000 mm3 [5,000-10,000 mm3]
- B. Hemoglobin 9 g/dL [Male: 14-18 g/dL (140-180 g/L) Female: 12-16 g/dL (120-160 g/L)]
- C. Calcium 8.6 mg/dL [9.0-10.5 mg/dL]
- D. Serum pH 7.33 [7.35-7.45]
Correct Answer: A
Rationale: Elevated WBC (19,000 mm3) suggests infection, a serious complication in peritoneal dialysis.
The nurse is caring for a client who is severely hypernatremic. The nurse should prioritize assessing the client's
- A. cardiovascular status.
- B. genitourinary status.
- C. neurological status.
- D. gastrointestinal status.
Correct Answer: C
Rationale: Hypernatremia affects neurological status due to cellular dehydration, causing confusion, seizures, or coma, requiring priority assessment.
The nurse is preparing to admit a client with chronic kidney disease and congestive heart failure. Which assessment would most effectively determine the client's fluid balance?
- A. Daily weight
- B. Intake and output measurement
- C. Urine specific gravity
- D. Serum sodium level
Correct Answer: A
Rationale: Daily weight is the most effective way to assess fluid balance, reflecting changes in fluid status.