Nokea
When the client asks the nurse to clarify the surgeon's explanation of the procedure, which statement is most accurate?
- A. Your urine will be deposited in your small intestine.
- B. Urine will be eliminated with stool from the rectum.
- C. Urine will drain from an abdominal opening.
- D. Your urine will empty from a special catheter.
Correct Answer: C
Rationale: An ileal conduit diverts urine to an abdominal stoma, where it drains externally.
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The client has received IV solutions for three (3) days through a 20-gauge IV catheter placed in the left cephalic vein. On morning rounds, the nurse notes the IV site is tender to palpation and a red streak has formed. Which intervention should the nurse implement first?
- A. Start a new IV in the right hand.
- B. Discontinue the intravenous line.
- C. Complete an incident record.
- D. Place a warm washrag over the site.
Correct Answer: B
Rationale: Tenderness and a red streak indicate phlebitis or infection. Discontinuing the IV line prevents further complications. Starting a new IV, completing an incident report, or applying warmth are secondary actions.
In evaluating multiple clients with UTIs, the clinic nurse should identify which client to be at least risk for developing a UT1?
- A. A client with urethral mucosa damage
- B. A client with an altered mental condition
- C. A client with an altered metabolic state
- D. An immunocompromised client
Correct Answer: C
Rationale: An altered metabolic state, without specific risk factors like diabetes, poses the least risk for UTIs compared to mucosal damage, mental status changes, or immunosuppression.
The client is diagnosed with an acute episode of ureteral calculi. Which client problem is priority when caring for this client?
- A. Fluid volume loss.
- B. Knowledge deficit.
- C. Impaired urinary elimination.
- D. Alteration in comfort.
Correct Answer: D
Rationale: Severe pain (alteration in comfort) is the priority in acute ureteral calculi, as it affects the client’s immediate well-being and requires prompt management. Fluid loss, urinary elimination, and knowledge are secondary.
On the basis of the nurse's knowledge of patient rights, which Federal law has the PCT violated?
- A. Good samarian Act
- B. Uncontractic Oath
- C. Health Insurance Portability and Accountability Act (HIPAA)
- D. Emergency Medical Treatment and Liability Act (EMTALA)
Correct Answer: C
Rationale: The PCT violated HIPAA by discussing the client's condition loudly in a public area, compromising patient confidentiality.
The nurse is providing discharge teaching to the client diagnosed with polycystic kidney disease. Which statement made by the client indicates the teaching has been effective?
- A. I need to avoid any activity causing a risk for injury to my kidney.'
- B. I should avoid taking medications for high blood pressure.'
- C. When I urinate there may be blood streaks in my urine.'
- D. I may have occasional burning when I urinate with this disease.'
Correct Answer: A
Rationale: Polycystic kidney disease causes enlarged, cystic kidneys prone to rupture. Avoiding trauma (e.g., contact sports) is critical. BP meds are necessary, hematuria is not expected, and burning suggests UTI.