Nokea
When documenting the client's urine output in the medical record, which measurement is correct for the nurse to record?
- A. Only the output from the urethral catheter
- B. Only the output from the wound catheter
- C. The outputs from each catheter separately
- D. The combined output from both catheters
Correct Answer: D
Rationale: The combined output from both catheters provides the total urine output, which is essential for accurate monitoring.
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The client is in the intensive care department (ICD) after a motor-vehicle accident in which the client lost an estimated three (3) units of blood. Which action by the nurse could prevent the client from developing acute renal failure?
- A. Take and document the client’s vital signs every hour.
- B. Assess the client’s dressings every two (2) hours.
- C. Check the client’s urinary output every shift.
- D. Maintain the client’s blood pressure greater than 100/60.
Correct Answer: D
Rationale: Significant blood loss risks prerenal ARF due to hypoperfusion. Maintaining BP above 100/60 ensures adequate renal perfusion. Vital signs, dressing checks, and urine output monitoring are supportive but less preventive.
The elderly client presents to the emergency department complaining of burning on urination with an urgency to void, and a temperature of 99.8°F. Which intervention should the nurse implement first?
- A. Ask the client to provide a clean voided midstream urine for culture.
- B. Insert an 18-gauge peripheral IV catheter and start normal saline fluids.
- C. Arrange for the client to be admitted to the medical unit.
- D. Initiate the ordered intravenous antibiotic medication.
Correct Answer: A
Rationale: Burning, urgency, and low-grade fever suggest a UTI. A midstream urine culture is the first step to confirm the diagnosis and guide treatment. IV fluids, admission, or antibiotics follow after diagnostic confirmation.
Which comment is the best response the nurse can offer?
- A. You're a very nice person.
- B. You're a very nice person.
- C. You should expect this at your age.
- D. You're discouraged right now.
Correct Answer: D
Rationale: Acknowledging the client's feelings of discouragement validates their emotional state and opens the door for supportive communication.
The nurse is caring for a client diagnosed with rule-out nephrotic syndrome. Which intervention should be included in the plan of care?
- A. Monitor the urine for bright-red bleeding.
- B. Evaluate the calorie count of the 500-mg protein diet.
- C. Assess the client’s sacrum for dependent edema.
- D. Monitor for a high serum albumin level.
Correct Answer: C
Rationale: Nephrotic syndrome is characterized by massive proteinuria, hypoalbuminemia, and edema, often dependent (e.g., in the sacrum in bedridden clients). Assessing for dependent edema is a key intervention to monitor disease progression or response to treatment. Bright-red bleeding is not typical, a 500-mg protein diet is incorrect, and high serum albumin is not expected.
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.