Nokea
The nurse is planning the care of a postoperative client with an ileal conduit. Which intervention should be included in the plan of care?
- A. Provide meticulous skin care and pouching.
- B. Apply sterile drainage bags daily.
- C. Monitor the pH of the urine weekly.
- D. Assess the stoma site every day.
Correct Answer: A
Rationale: Meticulous skin care and proper pouching prevent skin breakdown and infection around the ileal conduit stoma. Sterile bags are unnecessary, weekly pH monitoring is not standard, and daily stoma assessment is part of skin care.
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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 nurse is caring for the client diagnosed with chronic kidney disease (CKD) who is experiencing metabolic acidosis. Which statement best describes the scientific rationale for metabolic acidosis in this client?
- A. There is an increased excretion of phosphates and organic acids, which leads to an increase in arterial blood pH.
- B. A shortened life span of red blood cells because of damage secondary to dialysis treatments in turn leads to metabolic acidosis.
- C. The kidney cannot excrete increased levels of acid because they cannot excrete ammonia or cannot reabsorb sodium bicarbonate.
- D. An increase in nausea and vomiting causes a loss of hydrochloric acid and the respiratory system cannot compensate adequately.
Correct Answer: C
Rationale: In CKD, the kidneys fail to excrete acids (via ammonia) and reabsorb bicarbonate, leading to metabolic acidosis. Increased acid excretion would raise pH, RBC lifespan affects anemia, and vomiting causes alkalosis, not acidosis.
When administering the bladder instillation containing the chemotherapeutic drug, which safety precaution is most important for the nurse to take?
- A. Wear two pairs of latex gloves.
- B. As a mass syringe for the drug.
- C. Avoid wearing clothing with long sleeves.
- D. Limit contact time with the client.
Correct Answer: A
Rationale: Wearing two pairs of latex gloves protects the nurse from exposure to the chemotherapeutic drug during instillation.
Considering the amount of time the client must remain in bed, why is it imperative for the nurse to monitor for a urinary tract infection?
- A. The client will not be able to complete hygiene needs.
- B. The client will not be able to fully empty the bladder.
- C. The client will not be able to maintain bladder control.
- D. The client will not be able to drink sufficient fluids.
Correct Answer: B
Rationale: Prolonged bed rest can lead to incomplete bladder emptying, increasing the risk of urinary stasis and subsequent urinary tract infections.
The nurse is admitting a client diagnosed with acute renal failure (ARF). Which question is most important for the nurse to ask during the admission interview?
- A. Have you recently traveled outside the United States?
- B. Did you recently begin a vigorous exercise program?
- C. Is there a chance you have been exposed to a virus?
- D. What over-the-counter medications do you take regularly?
Correct Answer: D
Rationale: Acute renal failure can be caused by nephrotoxic agents, including over-the-counter medications like NSAIDs. Asking about medication use identifies potential causes of ARF, which is more directly relevant than travel, exercise, or viral exposure.