Which client should the nurse not assign to a UAP working on...

Which client should the nurse not assign to a UAP working on a surgical floor?

A. The client with a suprapubic catheter inserted yesterday.
B. The client who has had an indwelling catheter for the past week.
C. The client who is on a bladder-training regimen.
D. The client who had a catheter removed this morning and is being discharged.

Correct Answer: C

Rationale: A client on a bladder-training regimen requires nursing judgment to assess progress and adjust the plan, which is outside the UAP’s scope. Routine catheter care or post-removal care can be assigned.

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The female client in an outpatient clinic is being sent home with a diagnosis of urinary tract infection (UTI). Which instruction should the nurse teach to prevent a recurrence of a UTI?

A. Clean the perineum from back to front after a bowel movement.
B. Take warm tub baths instead of hot showers daily.
C. Void immediately preceding sexual intercourse.
D. Avoid coffee, tea, colas, and alcoholic beverages.

Correct Answer: D

Rationale: Avoiding bladder irritants like coffee, tea, colas, and alcohol reduces UTI recurrence risk. Wiping back to front increases infection risk, tub baths are less effective than showers, and voiding before intercourse is less critical than after.

The client returned from surgery after having a TURP and has a P 110, R 24, BP 90/40, and cool and clammy skin. Which interventions should the nurse implement? Select all that apply.

A. Assess the urine in the continuous irrigation drainage bag.
B. Decrease the irrigation fluid in the continuous irrigation catheter.
C. Lower the head of the bed while raising the foot of the bed.
D. Contact the surgeon to give an update on the client’s condition.
E. Check the client’s postoperative creatinine and BUN.

Correct Answer: A,C,D

Rationale: Tachycardia, hypotension, and clammy skin suggest hypovolemic shock, likely from bleeding. Assess urine for blood, use Trendelenburg to improve perfusion, and notify the surgeon. Decreasing irrigation may worsen clotting, and lab checks are less urgent.

Which intervention is most important for the nurse to implement for the client with a left nephrectomy?

A. Assess the intravenous fluids for rate and volume.
B. Change surgical dressing every day at the same time.
C. Monitor the client’s PT/PTT/INR level daily.
D. Monitor the percentage of each meal eaten.

Correct Answer: A

Rationale: Post-nephrectomy, maintaining adequate hydration and perfusion to the remaining kidney is critical to prevent acute kidney injury. Assessing IV fluid rate and volume ensures proper fluid balance. Dressing changes, coagulation monitoring, and meal intake are less urgent.

Which dietary recommendation should the nurse provide to the client to prevent the recurrence of calcium oxalate stones?

A. Increase intake of leafy green vegetables
B. Limit intake of oxalate-rich foods
C. Avoid all protein-rich foods
D. Decrease fluid intake

Correct Answer: B

Rationale: Limiting oxalate-rich foods (e.g., spinach, nuts) reduces the formation of calcium oxalate stones.

The client diagnosed with diabetes insipidus weighed 180 pounds when the daily weight was taken yesterday. This morning’s weight is 175.6 pounds. One liter of fluid weighs approximately 2.2 pounds. How much fluid has the client lost?

Correct Answer: 2 L

Rationale: Weight loss: 180 - 175.6 = 4.4 pounds. Fluid loss: 4.4 pounds ÷ 2.2 pounds/L = 2 L. This calculation accounts for fluid loss typical in diabetes insipidus due to excessive urination.