Nokea
The nurse is developing a plan of care for a client diagnosed with ARF. Which statement is an appropriate outcome for the client?
- A. Monitor intake and output every shift.
- B. Decrease of pain by three (3) levels on a 1-to-10 scale.
- C. Electrolytes are within normal limits.
- D. Administer enemas to decrease hyperkalemia.
Correct Answer: C
Rationale: An appropriate outcome for ARF is achieving normal electrolyte levels, as imbalances like hyperkalemia are common. Monitoring intake/output and administering enemas are interventions, not outcomes, and pain reduction is less specific to ARF.
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The nurse is preparing a teaching care plan for the client diagnosed with nephrotic syndrome. Which intervention should the nurse include?
- A. Stop steroids if a moon face develops.
- B. Provide teaching for taking diuretics.
- C. Increase the intake of dietary sodium.
- D. Report a decrease in daily weight.
Correct Answer: B
Rationale: Diuretics are commonly prescribed in nephrotic syndrome to manage edema. Teaching proper diuretic use (e.g., timing, side effects like hypokalemia) is essential. Stopping steroids for moon face is incorrect, increasing sodium worsens edema, and weight loss is expected, not a concern.
Which modifiable risk factor should the nurse identify for the development of cancer of the bladder in a client?
- A. Previous exposure to chemicals.
- B. Pelvic radiation therapy.
- C. Cigarette smoking.
- D. Parasitic infections of the bladder.
Correct Answer: C
Rationale: Cigarette smoking is a major modifiable risk factor for bladder cancer due to carcinogenic compounds in tobacco. Chemical exposure and radiation are risks but less modifiable, and parasitic infections are rare.
When the client with an ileal conduit expresses concern about odor, which recommendation by the nurse is most effective?
- A. Place an aspirin tablet in the pouch.
- B. Use a deodorizing pouch spray.
- C. Change the pouch daily.
- D. Avoid acidic foods.
Correct Answer: B
Rationale: Using a deodorizing pouch spray effectively controls odor, addressing the client's concern.
The client has received IV solutions for three (3) days through a 20-gauge IV catheter placed in the left cephalic vein. On morning rounds, the nurse notes the IV site is tender to palpation and a red streak has formed. Which intervention should the nurse implement first?
- A. Start a new IV in the right hand.
- B. Discontinue the intravenous line.
- C. Complete an incident record.
- D. Place a warm washrag over the site.
Correct Answer: B
Rationale: Tenderness and a red streak indicate phlebitis or infection. Discontinuing the IV line prevents further complications. Starting a new IV, completing an incident report, or applying warmth are secondary actions.
The nurse is caring for a client diagnosed with ARF. Which laboratory values are most significant for diagnosing ARF?
- A. BUN and creatinine.
- B. WBC and hemoglobin.
- C. Potassium and sodium.
- D. Bilirubin and ammonia level.
Correct Answer: A
Rationale: Elevated blood urea nitrogen (BUN) and creatinine levels indicate impaired kidney function, making them the primary markers for diagnosing ARF. Other labs like WBC, electrolytes, or liver function tests are less specific for ARF diagnosis.