Nokea
The nurse writes the client problem of 'fluid volume excess' (FVE). Which intervention should be included in the plan of care?
- A. Change the IV fluid from 0.9% NS to D5W.
- B. Restrict the sodium in the client’s diet.
- C. Monitor blood glucose levels.
- D. Prepare the client for hemodialysis.
Correct Answer: B
Rationale: Restricting sodium reduces fluid retention in FVE, as sodium promotes water reabsorption. D5W provides free water, worsening FVE; glucose monitoring is unrelated; and hemodialysis is reserved for severe cases.
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Which intervention should the nurse include when preparing a teaching plan for the client with chronic prostatitis?
- A. Sit in a warm sitz bath for 10 to 20 minutes several times daily.
- B. Sit in the chair with the feet elevated for two (2) hours daily.
- C. Drink at least 3,000 mL of oral fluids, especially tea and coffee, daily.
- D. Stop broad-spectrum antibiotics as soon as the symptoms subside.
Correct Answer: A
Rationale: Warm sitz baths reduce inflammation and pain in chronic prostatitis. Elevating feet is unrelated, tea/coffee are bladder irritants, and stopping antibiotics early risks recurrence.
When managing catheter care, which nursing action is most important for promoting wound healing?
- A. Avoid tension on the catheter.
- B. Encourage oral fluid intake.
- C. Clean the urethral meatus daily.
- D. Clamp and release the catheter every 2 hours.
Correct Answer: A
Rationale: Avoiding tension on the catheter prevents trauma to the surgical site, promoting healing.
The female client diagnosed with bladder cancer who has a cutaneous urinary diversion states, 'Will I be able to have children now?' Which statement is the nurse’s best response?
- A. Cancer does not make you sterile, but sometimes the therapy can.'
- B. Are you concerned you can’t have children?'
- C. You will be able to have as many children as you want.'
- D. Let me have the chaplain come to talk with you about this.'
Correct Answer: A
Rationale: Bladder cancer itself does not cause sterility, but treatments (e.g., chemotherapy, radiation) may affect fertility. This response is accurate and informative. Reflecting concern, promising fertility, or referring to a chaplain avoids the question.
The client diagnosed with chronic renal failure (CRF) is prescribed a 60-gm protein, 2,000-mg sodium diet. Which food choices indicate the client understands the dietary restrictions?
- A. A 4-ounce grilled chicken breast, broccoli, and small glass of unsweet tea.
- B. A baked potato with chopped ham and sour cream, 12-ounce steak, and beer.
- C. A double patty cheeseburger, french fries, and saccharin sweet Kool Aid.
- D. A roast beef sandwich, potato chips, and soft drink.
Correct Answer: A
Rationale: A 4-oz chicken breast (≈28 g protein), broccoli, and tea are low-sodium and fit the 60-g protein, 2,000-mg sodium diet. Other options exceed protein/sodium limits with high-sodium foods (ham, cheeseburger, chips).
When asked about factors that are linked to bladder cancer, the nurse correctly identifies which factors? Select all that apply.
- A. Stress incontinence
- B. Frequent intercourse
- C. Sexual promiscuity
- D. Cigarette smoking
- E. History of prostate cancer
- F. Exposure to asbestos
Correct Answer: D
Rationale: Cigarette smoking is a well-established risk factor for bladder cancer.