Nokea
When assessing for dehydration, the nurse should observe for which of the following?
- A. Headache and increased urinary output
- B. Weight gain and edema
- C. Hypertension and decreased urinary output
- D. Hypotension, headache, and dry mucous membranes
Correct Answer: D
Rationale: Dehydration causes hypotension, headache, and dry mucous membranes due to fluid loss.
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The nurse cares for a client with a serum sodium level of 152 mEq/L (mmol/L) [135-145 mEq/L, mmol/L]. Which of the following assessment findings would be expected? Select all that apply.
- A. Lethargy
- B. Dry mucous membranes
- C. Tachypnea
- D. Cyanosis
- E. Excessive thirst
Correct Answer: A,B,E
Rationale: Hypernatremia causes lethargy, dry mucous membranes, and excessive thirst due to cellular dehydration.
A client with benign prostatic hyperplasia (BPH) is post-operative following transurethral resection of the prostate (TURP) and is now receiving continuous bladder irrigation. Upon assessment, the nurse notes that the output from the urinary catheter has stopped. Which nursing intervention is most appropriate?
- A. Reinsert a new catheter
- B. Increase the infusion rate of the irrigation
- C. Attempt to dislodge a clot
- D. Contact the health care provider (HCP)
Correct Answer: C
Rationale: Attempting to dislodge a clot is appropriate to restore flow, as catheter obstruction is common post-TURP.
Following surgery for a prolapsed bladder, a 74-year-old female client is two days postoperative with an indwelling urinary catheter. While the nurse is making morning rounds, the client states, 'I feel like peeing again!' The most appropriate response for the nurse is:
- A. It's just bladder spasms. Nothing to worry about.'
- B. Let me look at your urine bag to ensure it's draining properly.'
- C. You should do Kegel exercises regularly to stop this urge to void.'
- D. Is this the first time this has happened?'
Correct Answer: B
Rationale: Checking the urine bag ensures the catheter is draining properly, addressing the sensation of needing to urinate.
The nurse is providing discharge instructions to a client prescribed phenazopyridine. Which of the following instructions should the nurse include?
- A. The amount of urine you void will increase
- B. Your urine will turn orange in color
- C. You may notice that your urine is malodorous
- D. Concentrated urine is an expected finding
Correct Answer: B
Rationale: Phenazopyridine causes orange-colored urine, a common side effect to inform clients about.
The nurse is assessing a client with suspected renal calculi. Which of the following findings would support a diagnosis of renal calculi? Select all that apply.
- A. hematuria
- B. nausea and vomiting
- C. hypotension
- D. dysuria
- E. increased urinary frequency
Correct Answer: A,B,D,E
Rationale: Renal calculi cause hematuria, nausea, vomiting, dysuria, and increased urinary frequency due to irritation and obstruction.