Nokea
The nurse performs bladder irrigation through an indwelling catheter. The nurse instilled 90 mL of sterile normal saline. The catheter drained 710 mL. What is the client’s output?
Correct Answer: 620 mL
Rationale: Urine output = Total drainage - Irrigation fluid instilled = 710 mL - 90 mL = 620 mL. This isolates the client’s actual urine production from the irrigation fluid.
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A nurse is assigned to care for a client with a cutaneous ureterostomy. Which of the following images correlates with the client's urinary diversion?
- A. Image A
- B. Image B
- C. Image C
- D. Image D
Correct Answer: C
Rationale: A cutaneous ureterostomy involves the ureters being brought to the skin surface, typically depicted as a stoma on the abdomen, which corresponds to a specific image (assumed as C based on standard depictions).
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.
Which intervention is most important for the nurse to implement for the client with a left nephrectomy?
- A. Assess the intravenous fluids for rate and volume.
- B. Change surgical dressing every day at the same time.
- C. Monitor the client’s PT/PTT/INR level daily.
- D. Monitor the percentage of each meal eaten.
Correct Answer: A
Rationale: Post-nephrectomy, maintaining adequate hydration and perfusion to the remaining kidney is critical to prevent acute kidney injury. Assessing IV fluid rate and volume ensures proper fluid balance. Dressing changes, coagulation monitoring, and meal intake are less urgent.
Which finding provides the best evidence that peritoneal dialysis is achieving a therapeutic effect?
- A. Urine output increases.
- B. Appetite improves.
- C. Red blood cell count is lower.
Correct Answer: B
Rationale: Improved appetite indicates reduced uremia, a sign that dialysis is effectively removing toxins.
The client is one (1) day postoperative TURP. Which task should the nurse delegate to the UAP?
- A. Increase the irrigation fluid to clear clots from the tubing.
- B. Elevate the scrotum on a towel roll for support.
- C. Change the dressing on the first postoperative day.
- D. Teach the client how to care for the continuous irrigation catheter.
Correct Answer: B
Rationale: Elevating the scrotum is a simple supportive task within the UAP’s scope. Adjusting irrigation, changing dressings, and teaching require nursing judgment and are not delegable.