Nokea
When the client with an ileal conduit asks about resuming physical activity, which response by the nurse is most appropriate?
- A. Avoid all strenuous activity permanently.
- B. Resume activities gradually as tolerated.
- C. Wait at least 6 months before exercising.
- D. Limit activity to walking only.
Correct Answer: B
Rationale: Resuming activities gradually as tolerated allows the client to regain strength while protecting the stoma.
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Which statement indicates discharge teaching has been effective for the client who is postoperative TURP?
- A. I will call the surgeon if I experience any difficulty urinating.'
- B. I will take my Proscar daily, the same as before my surgery.'
- C. I will continue restricting my oral fluid intake.'
- D. I will take my pain medication routinely even if I do not hurt.'
Correct Answer: A
Rationale: Difficulty urinating post-TURP may indicate obstruction or complications, requiring prompt reporting. Proscar is typically discontinued post-TURP, fluid restriction is unnecessary, and routine pain meds are not advised.
The nurse is inserting an indwelling catheter into a female client. Which interventions should be implemented? Rank in the order of performance.
- A. Explain the procedure to the client.
- B. Set up the sterile field.
- C. Inflate the catheter bulb.
- D. Place absorbent pads under the client.
- E. Clean the perineum from clean to dirty with Betadine.
Correct Answer: A,D,B,E,C
Rationale: Correct order: 1) Explain the procedure to gain consent and reduce anxiety; 2) Place absorbent pads to maintain a clean field; 3) Set up the sterile field to prepare equipment; 4) Clean the perineum (front to back, not clean to dirty, assuming document error) to reduce infection risk; 5) Inflate the catheter bulb after insertion to secure it.
Which intervention should the nurse implement when caring for the client with a nephrostomy tube?
- A. Change the dressing only if soiled by urine.
- B. Clean the end of the connecting tubing with Betadine.
- C. Clean the drainage system every day with bleach and water.
- D. Assess the tube for kinks to prevent obstruction.
Correct Answer: D
Rationale: Assessing for kinks ensures patency of the nephrostomy tube, preventing urine backup and complications. Dressings are changed regularly, Betadine is not used for tubing, and bleach cleaning is inappropriate.
The client diagnosed with a urinary tract infection has a blood pressure of 83/56 mm Hg and a pulse of 122 bpm. Which should the nurse implement first?
- A. Notify the health-care provider (HCP).
- B. Hang the IVPB antibiotic at the prescribed rate.
- C. Check the laboratory work to determine if the urine culture has been completed.
- D. Increase the normal saline IV fluids from keep open to 150 mL/hour on the IV pump.
Correct Answer: D
Rationale: Hypotension (83/56) and tachycardia (122 bpm) suggest septic shock from the UTI. Increasing IV fluids to 150 mL/hour improves perfusion, stabilizing the client. Notification, antibiotics, and lab checks are secondary to immediate fluid resuscitation.
When the client complains about the bland taste of the food, the nurse appropriately recommends substituting salt with a bloodiness?
- A. Catsup
- B. Mustard
- C. Soy sauce
- D. Lemon juice
Correct Answer: D
Rationale: Lemon juice is a low-sodium flavor enhancer, suitable for a sodium-restricted diet, unlike catsup, mustard, or soy sauce.