Nokea
The nurse is developing a care map to care for a client diagnosed with chronic renal failure (CRF) on hemodialysis. Which interrelated concepts should be included in the map? Select all that apply.
- A. Fluid and electrolytes.
- B. Hematologic regulation.
- C. Digestion.
- D. Metabolism.
- E. Mobility.
- F. Nutrition.
Correct Answer: A,B,D,F
Rationale: CRF affects fluid/electrolyte balance (impaired excretion), hematologic regulation (anemia from low erythropoietin), metabolism (altered drug clearance), and nutrition (dietary restrictions). Digestion and mobility are less directly impacted.
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Which response by the nurse is most appropriate?
- A. His bladder retraining is coming along, and before long he will be urinating like normal.
- B. He seems to have more incontinence in the afternoon and evening.
- C. In order to protect his privacy, I can't give you that information.
- D. Bladder retraining is slow work. We have to take him to the toilet every 2 hours.
Correct Answer: C
Rationale: To comply with HIPAA, the nurse must protect the client's privacy and not disclose health information without consent, making this the most appropriate response.
The client with possible renal calculi is scheduled for a renal ultrasound. Which intervention should the nurse implement for this procedure?
- A. Ask if the client is allergic to shellfish or iodine.
- B. Keep the client NPO eight (8) hours prior to the ultrasound.
- C. Ensure the client has a signed informed consent form.
- D. Explain the test is noninvasive and there is no discomfort.
Correct Answer: D
Rationale: Renal ultrasound is noninvasive, painless, and requires minimal preparation. Explaining this reduces anxiety. No contrast (iodine) is used, NPO is unnecessary, and informed consent is not typically required.
The client diagnosed with diabetes insipidus weighed 180 pounds when the daily weight was taken yesterday. This morning’s weight is 175.6 pounds. One liter of fluid weighs approximately 2.2 pounds. How much fluid has the client lost?
Correct Answer: 2 L
Rationale: Weight loss: 180 - 175.6 = 4.4 pounds. Fluid loss: 4.4 pounds ÷ 2.2 pounds/L = 2 L. This calculation accounts for fluid loss typical in diabetes insipidus due to excessive urination.
The client is two (2) days postureterosigmoidostomy for cancer of the bladder. Which assessment data warrant notification of the HCP by the nurse?
- A. The client complains of pain at a '3,' 30 minutes after being medicated.
- B. The client complains it hurts to cough and deep breathe.
- C. The client ambulates to the end of the hall and back before lunch.
- D. The client is lying in a fetal position and has a rigid abdomen.
Correct Answer: D
Rationale: A rigid abdomen and fetal position suggest peritonitis or other serious complications (e.g., anastomotic leak) post-ureterosigmoidostomy, requiring immediate HCP notification. Mild pain, coughing discomfort, and ambulation are less urgent.
When the nurse reviews the client's medical history, which finding most likely precipitated the present illness?
- A. A recent streptococcal throat infection
- B. A recent influenza infection
- C. A recent episode of gastroenteritis
- D. A recent urinary tract infection
Correct Answer: A
Rationale: A recent streptococcal throat infection is a common trigger for acute glomerulonephritis due to immune-mediated kidney damage.