Nokea
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.
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The client with CKD is placed on a fluid restriction of 1,500 mL/day. On the 7 a.m. to 7 p.m. shift the client drank an eight (8)-ounce cup of coffee, 4 ounces of juice, 12 ounces of tea, and 2 ounces of water with medications. What amount of fluid can the 7 p.m. to 7 a.m. nurse give to the client?
Correct Answer: 720 mL
Rationale: Convert ounces to mL (1 oz ≈ 30 mL): Coffee: 8 oz = 240 mL, Juice: 4 oz = 120 mL, Tea: 12 oz = 360 mL, Water: 2 oz = 60 mL. Total consumed: 240 + 120 + 360 + 60 = 780 mL. Daily limit: 1,500 mL. Remaining: 1,500 - 780 = 720 mL.
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.
The nurse is caring for the client recovering from a percutaneous renal biopsy. Which data indicate the client is complying with client teaching?
- A. The client is lying flat in the saline position.
- B. The client continues oral fluids restriction while on bedrest.
- C. The client uses the bedside commode to urinate.
- D. The client refuses to ask for any pain medication.
Correct Answer: A
Rationale: Post-renal biopsy, lying flat (supine, assuming 'saline' is a typo) prevents bleeding complications, indicating compliance. Fluid restriction is unnecessary, using a commode risks bleeding, and refusing pain meds is unrelated.
Which intervention is most important for the nurse to implement for the client diagnosed with rule-out renal calculi?
- A. Assess the client’s neurological status every two (2) hours.
- B. Strain all urine and send any sediment to the laboratory.
- C. Monitor the client’s creatinine and BUN levels.
- D. Take a 24-hour dietary recall during the client interview.
Correct Answer: B
Rationale: Straining urine to capture stones or sediment is critical for diagnosing renal calculi, as it confirms the presence and type of stones. Neurological status, lab monitoring, and dietary recall are secondary.
The nurse is preparing the plan of care for the client diagnosed with a neurogenic flaccid bladder. Which expected outcome is appropriate for this client?
- A. The client has conscious control over bladder activity.
- B. The client’s bladder does not become overdistended.
- C. The client has bladder sensation and no discomfort.
- D. The client demonstrates how to check for bladder distention.
Correct Answer: B
Rationale: A neurogenic flaccid bladder lacks tone, risking overdistention. Preventing this is a key outcome to avoid complications like infection or reflux. Conscious control and sensation are unlikely, and checking distention is an intervention.