Nokea
When the nurse interviews the client, which symptoms will the client most likely report if a bladder infection has been acquired? Select all that apply.
- A. Sharp flank pain
- B. Uretrail discharge
- C. Strong-smelling urine
- D. Burning on urination
- E. Urgency
- F. Frequency
Correct Answer: C,D,E,F
Rationale: Symptoms of a bladder infection typically include strong-smelling urine, burning on urination, urgency, and frequency, as these reflect irritation and inflammation of the bladder.
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The client receiving hemodialysis is being discharged home from the dialysis center. Which instruction should the nurse teach the client?
- A. Notify the HCP if oral temperature is 102°F or greater.
- B. Apply ice to the access site if it starts bleeding at home.
- C. Keep fingernails short and try not to scratch the skin.
- D. Encourage the significant other to make decisions for the client.
Correct Answer: A
Rationale: A fever of 102°F or higher may indicate infection, a serious complication in hemodialysis patients, requiring prompt HCP notification. Ice may worsen bleeding, short nails are general advice, and encouraging dependency is not therapeutic.
Which assessment supports the nurse's assumption that the client's sleep disturbance was most likely due to anxiety?
- A. The client was pacing the room before bedtime.
- B. The client's vital signs were stable during the night.
- C. The client requested a sleeping pill earlier.
- D. The client reported feeling rested in the morning.
Correct Answer: A
Rationale: Pacing before bedtime is a behavioral sign of anxiety, supporting the assumption that anxiety caused the sleep disturbance.
After the cystoscopy, which urinary symptom can the nurse expect the client to report?
- A. A sense of urgency
- B. No urinary output
- C. A strong urinary odor
- D. A large volume of urine output
Correct Answer: A
Rationale: A sense of urgency is common after cystoscopy due to urethral irritation from the procedure.
The female client diagnosed with bladder cancer who has a cutaneous urinary diversion states, 'Will I be able to have children now?' Which statement is the nurse’s best response?
- A. Cancer does not make you sterile, but sometimes the therapy can.'
- B. Are you concerned you can’t have children?'
- C. You will be able to have as many children as you want.'
- D. Let me have the chaplain come to talk with you about this.'
Correct Answer: A
Rationale: Bladder cancer itself does not cause sterility, but treatments (e.g., chemotherapy, radiation) may affect fertility. This response is accurate and informative. Reflecting concern, promising fertility, or referring to a chaplain avoids the question.
The client has been vomiting and has had numerous episodes of diarrhea. Which laboratory test should the nurse monitor?
- A. Serum calcium.
- B. Serum phosphorus.
- C. Serum potassium.
- D. Serum sodium.
Correct Answer: C
Rationale: Vomiting and diarrhea cause significant potassium loss, leading to hypokalemia, which can cause arrhythmias. Calcium, phosphorus, and sodium are less critically affected in this scenario.