Nokea
The UAP tells the nurse the client with ARF has a white crystal-like layer on top of the skin. Which intervention should the nurse implement?
- A. Have the assistant apply a moisture barrier cream to the skin.
- B. Instruct the UAP to bathe the client in cool water.
- C. Tell the UAP not to turn the client in this condition.
- D. Explain this is normal and do not do anything for the client.
Correct Answer: D
Rationale: The white crystal-like layer is uremic frost, a result of urea crystallizing on the skin due to severe uremia in ARF. This is an expected finding and requires no specific intervention beyond routine skin care and dialysis to address uremia.
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The client diagnosed with ARF is admitted to the intensive care department and placed on a therapeutic diet. Which diet is most appropriate for the client?
- A. A high-potassium and low-calcium diet.
- B. A low-fat and low-cholesterol diet.
- C. A high-carbohydrate and restricted-protein diet.
- D. A regular diet with six (6) small feedings a day.
Correct Answer: C
Rationale: ARF patients require a restricted-protein diet to reduce urea production and a high-carbohydrate diet to provide energy, minimizing protein catabolism. High-potassium diets are contraindicated due to hyperkalemia risk, and low-fat or regular diets are less specific.
Which response by the nurse is most appropriate?
- A. His bladder retraining is coming along, and before long he will be urinating like normal.
- B. He seems to have more incontinence in the afternoon and evening.
- C. In order to protect his privacy, I can't give you that information.
- D. Bladder retraining is slow work. We have to take him to the toilet every 2 hours.
Correct Answer: C
Rationale: To comply with HIPAA, the nurse must protect the client's privacy and not disclose health information without consent, making this the most appropriate response.
Which statement by the client with an ileal conduit indicates a need for further teaching?
- A. I will change the pouch every 5 to 7 days.
- B. I will keep the skin around the stoma clean and dry.
- C. I will empty the pouch when it is one-third full.
- D. I will avoid drinking fluids to reduce urine output.
Correct Answer: D
Rationale: Avoiding fluids is incorrect, as adequate fluid intake is necessary to maintain urine flow and prevent complications.
The nurse and an unlicensed assistive personnel (UAP) are caring for a group of clients. Which nursing intervention should the nurse perform?
- A. Measure the client’s output from the indwelling catheter.
- B. Record the client’s intake and output on the I&O sheet.
- C. Instruct the client on appropriate fluid restrictions.
- D. Provide water for a client diagnosed with diabetes insipidus.
Correct Answer: C
Rationale: Instructing on fluid restrictions requires nursing judgment and education skills, which are outside the UAP’s scope. Measuring output, recording I&O, and providing water are delegable tasks.
The nurse identifies the concepts of elimination and immunity for a female client diagnosing with a urinary tract infection. Which discharge instructions should the nurse provide the client? Select all that apply.
- A. Teach the client to wipe from front to back after voiding.
- B. Encourage the client to drink cranberry juice each morning.
- C. Inform the client that frequent episodes of incontinence are expected.
- D. Discuss the signs and symptoms of a recurrent infection.
- E. Have the client fill a container of water to sip until at least 2,000 mL is consumed.
- F. Request that the client sit in a tub of warm water twice a day for 25 minutes.
Correct Answer: A,B,D,E
Rationale: Wiping front to back prevents bacterial spread, cranberry juice may reduce UTI risk, discussing recurrent symptoms aids early detection, and 2,000 mL fluid intake flushes the bladder. Incontinence is not expected, and tub baths increase infection risk.