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The nurse is caring for an elderly client who has an indwelling catheter. Which data warrant further investigation?
- A. The client’s temperature is 98°F.
- B. The client has become confused and irritable.
- C. The client’s urine is clear and light yellow.
- D. The client feels the need to urinate.
Correct Answer: B
Rationale: New-onset confusion and irritability in an elderly client with a catheter suggest a possible UTI, requiring investigation. Normal temperature, clear urine, and urge sensation are expected or less concerning.
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When the client complains about the bland taste of the food, the nurse appropriately recommends substituting salt with which condiment?
- A. Catsup
- B. Mustard
- C. Soy sauce
- D. Lemon juice
Correct Answer: D
Rationale: Lemon juice is a low-sodium flavor enhancer, suitable for a sodium-restricted diet, unlike catsup, mustard, or soy sauce.
When the nurse interviews the client, which symptoms will the client most likely report if a bladder infection has been acquired? Select all that apply.
- A. Sharp flank pain
- B. Uretrail discharge
- C. Strong-smelling urine
- D. Burning on urination
- E. Urgency
- F. Frequency
Correct Answer: C,D,E,F
Rationale: Symptoms of a bladder infection typically include strong-smelling urine, burning on urination, urgency, and frequency, as these reflect irritation and inflammation of the bladder.
The nurse is developing a nursing care plan for the client diagnosed with CKD. Which nursing problem is priority for the client?
- A. Low self-esteem.
- B. Knowledge deficit.
- C. Activity intolerance.
- D. Excess fluid volume.
Correct Answer: D
Rationale: Excess fluid volume is the priority in CKD due to impaired kidney excretion, leading to edema, hypertension, and heart failure risk. Fluid overload is a life-threatening issue, whereas self-esteem, knowledge, and activity intolerance are secondary.
The nurse writes the client problem of 'fluid volume excess' (FVE). Which intervention should be included in the plan of care?
- A. Change the IV fluid from 0.9% NS to D5W.
- B. Restrict the sodium in the client’s diet.
- C. Monitor blood glucose levels.
- D. Prepare the client for hemodialysis.
Correct Answer: B
Rationale: Restricting sodium reduces fluid retention in FVE, as sodium promotes water reabsorption. D5W provides free water, worsening FVE; glucose monitoring is unrelated; and hemodialysis is reserved for severe cases.
The client diagnosed with chronic renal failure (CRF) is prescribed a 60-gm protein, 2,000-mg sodium diet. Which food choices indicate the client understands the dietary restrictions?
- A. A 4-ounce grilled chicken breast, broccoli, and small glass of unsweet tea.
- B. A baked potato with chopped ham and sour cream, 12-ounce steak, and beer.
- C. A double patty cheeseburger, french fries, and saccharin sweet Kool Aid.
- D. A roast beef sandwich, potato chips, and soft drink.
Correct Answer: A
Rationale: A 4-oz chicken breast (≈28 g protein), broccoli, and tea are low-sodium and fit the 60-g protein, 2,000-mg sodium diet. Other options exceed protein/sodium limits with high-sodium foods (ham, cheeseburger, chips).