Nokea
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.
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Which statement indicates the client diagnosed with calcium phosphate renal calculi understands the discharge teaching for ways to prevent future calculi formation?
- A. I should increase my fluid intake, especially in warm weather.'
- B. I should eat foods containing cocoa and chocolate.'
- C. I will walk about a mile every week and not exercise often.'
- D. I should take one (1) vitamin a day with extra calcium.'
Correct Answer: A
Rationale: Increased fluid intake dilutes urine, reducing calcium phosphate stone formation, especially in warm weather when dehydration risk is higher. Cocoa/chocolate, minimal exercise, and extra calcium increase stone risk.
Which assessment finding indicates a potential complication of the client's ileal conduit?
- A. Clear, yellow urine in the pouch
- B. Mild redness around the stoma
- C. Foul-smelling, cloudy urine
- D. Urine output of 50 mL/hour
Correct Answer: C
Rationale: Foul-smelling, cloudy urine suggests a possible urinary tract infection, a common complication of an ileal conduit.
While the fluid is being administered, which nursing assessment is most important?
- A. Checking for pedal edema
- B. Assessing the rapid weight gain
- C. Monitoring specific gravity
- D. Auscultating breath sounds
Correct Answer: D
Rationale: Auscultating breath sounds is critical during a fluid challenge to detect signs of fluid overload, such as pulmonary edema.
The nurse is preparing the discharge teaching plan for the male client with a left-sided nephrectomy. Which statement indicates the teaching is effective?
- A. I can’t wait to start back to work next week, I really need the money.
- B. I will take my temperature and if it is above 101 I will call my doctor.
- C. I am glad I won’t have to keep track of how much I urinate in the day.
- D. I am happy I will be able eat what I usually eat, I don’t like this food.
Correct Answer: B
Rationale: Effective discharge teaching post-nephrectomy includes recognizing signs of infection, such as fever above 101°F, requiring prompt reporting. Returning to work too soon, not monitoring urine output, or resuming a normal diet may be incorrect.
The elderly client recovering from a prostatectomy has been experiencing stress incontinence. Which independent nursing intervention should the nurse discuss with the client?
- A. Establish a set voiding frequency of every two (2) hours while awake.
- B. Encourage a family member to assist the client to the bathroom to void.
- C. Apply a transurethral electrical stimulator to relieve symptoms of urinary urgency.
- D. Discuss the use of a 'bladder drill,' including a timed voiding schedule.
Correct Answer: D
Rationale: A bladder drill with timed voiding strengthens bladder control and reduces stress incontinence post-prostatectomy. Voiding every 2 hours is part of it, family assistance reduces independence, and electrical stimulators are not standard.