Nokea
The nurse is caring for a client diagnosed with rule-out nephrotic syndrome. Which intervention should be included in the plan of care?
- A. Monitor the urine for bright-red bleeding.
- B. Evaluate the calorie count of the 500-mg protein diet.
- C. Assess the client’s sacrum for dependent edema.
- D. Monitor for a high serum albumin level.
Correct Answer: C
Rationale: Nephrotic syndrome is characterized by massive proteinuria, hypoalbuminemia, and edema, often dependent (e.g., in the sacrum in bedridden clients). Assessing for dependent edema is a key intervention to monitor disease progression or response to treatment. Bright-red bleeding is not typical, a 500-mg protein diet is incorrect, and high serum albumin is not expected.
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After the TURP, which assessment finding would the nurse expect to observe during the immediate postoperative period?
- A. Light pink to clear urine
- B. Second sediments in urine
- C. Decreased volume of urine
- D. Grossly bloody urine
Correct Answer: D
Rationale: Grossly bloody urine is expected immediately after TURP due to surgical trauma to the prostate.
The nurse is discharging a client with a healthcare facility acquired urinary tract infection. Which information should the nurse include in the discharge teaching?
- A. Limit fluid intake so the urinary tract can heal.
- B. Collect a routine urine specimen for culture.
- C. Take all the antibiotics as prescribed.
- D. Tell the client to void every five (5) to six (6) hours.
Correct Answer: C
Rationale: Completing the full course of antibiotics prevents recurrence and resistance in UTIs. Limiting fluids increases infection risk, routine cultures are unnecessary, and voiding every 2–3 hours is preferred.
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 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.
The client is admitted to a nursing unit from a long-term care facility with a hematocrit of 56% and a serum sodium level of 152 mEq/L. Which condition is a cause for these findings?
- A. Overhydration.
- B. Anemia.
- C. Dehydration.
- D. Renal failure.
Correct Answer: C
Rationale: Elevated hematocrit (56%) and hypernatremia (152 mEq/L) indicate dehydration, which concentrates blood components and sodium. Overhydration dilutes these values, anemia lowers hematocrit, and renal failure typically causes hyponatremia.