Nokea
The nurse teaches the client with an ileal conduit measures to prevent a urinary loss. Which of the following measures would be most effective?
- A. Avoid people with respiratory tract infections.
- B. Maintain a daily fluid intake of 2,000 to 3,000 mL.
- C. Use sterile technique to change the appliance.
- D. Irrigate the stoma daily.
Correct Answer: B
Rationale: Maintaining high fluid intake (2,000-3,000 mL) prevents urinary stasis and infection, the most effective measure for reducing urinary loss risk.
You may also like to solve these questions
Because a client's renal stone was found to be composed of uric acid, a low-purine, alkaline-ash diet was ordered. Incorporation of which of the following food items into the home diet would indicate that the client understands the necessary diet modifications?
- A. Milk, apples, tomatoes, and corn.
- B. Eggs, spinach, dried peas, and gravy.
- C. Salmon, chicken, and asparagus.
- D. Grapes, corn, cereals, and liver.
Correct Answer: A
Rationale: Milk, apples, tomatoes, and corn are low-purine and promote an alkaline-ash diet, suitable for uric acid stone prevention.
In assessing a client in the early stage of chronic lymphocytic leukemia (CLL), the nurse should determine if the client has:
- A. Enlarged, painless lymph nodes.
- B. Headache.
- C. Hyperplasia of the gums.
- D. Unintentional weight loss.
Correct Answer: A
Rationale: Early-stage CLL is often asymptomatic but may present with enlarged, painless lymph nodes due to lymphocyte accumulation. Headache, gum hyperplasia, and weight loss are not typical early findings.
Which of the following nursing interventions is appropriate for a client with an increased intracranial pressure (ICP) of 20 mm Hg?
- A. Give the client a warming blanket.
- B. Administer low-dose barbiturates.
- C. Encourage the client to hyperventilate.
- D. Restrict fluids.
Correct Answer: B
Rationale: Low-dose barbiturates can reduce cerebral metabolism and ICP, making them appropriate in some cases under medical supervision. Warming blankets increase metabolic demand, hyperventilation is no longer routinely recommended due to risks of cerebral vasoconstriction, and fluid restriction is not standard for ICP management unless specifically indicated.
Which information should the nurse include when developing a teaching plan for a client newly diagnosed with type 2 diabetes mellitus. Select all that apply.
- A. A major risk factor for complications is obesity and central abdominal obesity.
- B. Supplemental insulin is mandatory for controlling the disease.
- C. Exercise increases insulin resistance.
- D. The primary nutritional source requiring monitoring in the diet is carbohydrates.
- E. Annual eye and foot examinations are recommended by the American Diabetes Association (ADA).
Correct Answer: A,D,E
Rationale: Obesity, especially central, is a major risk factor for complications. Carbohydrates require monitoring to manage blood glucose. Annual eye and foot exams are recommended. Insulin is not mandatory for type 2 diabetes, and exercise decreases insulin resistance.
Which nursing action is important in preventing cross-contamination?
- A. Change gloves immediately after use.
- B. Stand 2 feet from the client.
- C. Speak minimally when in the room.
- D. Wear long-sleeved shirts.
Correct Answer: A
Rationale: Changing gloves immediately after use prevents cross-contamination by removing potential pathogens from the nurse's hands before touching other surfaces or clients. The other actions are less effective in preventing contamination.