Nokea
Which finding provides the best evidence that peritoneal dialysis is achieving a therapeutic effect?
- A. Urine output increases.
- B. Appetite improves.
- C. Red blood cell count is lower.
Correct Answer: B
Rationale: Improved appetite indicates reduced uremia, a sign that dialysis is effectively removing toxins.
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Which intervention should the nurse implement first for the client who has had an incontinent episode?
- A. Palpate the client’s bladder to assess for urinary retention.
- B. Obtain a bedside commode for the client.
- C. Assist the client with changing the wet clothes.
- D. Request the UAP to change the client’s linens.
Correct Answer: C
Rationale: Assisting the client to change wet clothes addresses immediate comfort and dignity, preventing skin breakdown. Palpating the/moist bladder, obtaining a commode, or changing linens are secondary.
The client is 12 hours postoperative renal surgery. Which data warrant immediate intervention by the nurse?
- A. The abdomen is soft, nontender, and rounded.
- B. Pain is not felt with dorsal flexion of the foot.
- C. The urine output is 60 mL for the past two (2) hours.
- D. The client’s trough vancomycin level is 24 mcg/mL.
Correct Answer: D
Rationale: A vancomycin level of 24 mcg/mL is above the therapeutic range (10–20 mcg/mL), risking nephrotoxicity, especially post-renal surgery. Soft abdomen, no pain on dorsiflexion, and 60 mL urine output are normal.
The nurse and an unlicensed assistive personnel (UAP) are caring for a group of clients. Which nursing intervention should the nurse perform?
- A. Measure the client’s output from the indwelling catheter.
- B. Record the client’s intake and output on the I&O sheet.
- C. Instruct the client on appropriate fluid restrictions.
- D. Provide water for a client diagnosed with diabetes insipidus.
Correct Answer: C
Rationale: Instructing on fluid restrictions requires nursing judgment and education skills, which are outside the UAP’s scope. Measuring output, recording I&O, and providing water are delegable tasks.
Which nursing action is most appropriate when the client complains about being thirsty because of the fluid restrictions?
- A. Giving the client hard candy to suck
- B. Providing the client with ice chips
- C. Offering the client an ice cream bar
- D. Supplying the client with fresh fruit
Correct Answer: A
Rationale: Hard candy stimulates saliva production, alleviating thirst without contributing to fluid intake, which is restricted.
The client is two (2) days postureterosigmoidostomy for cancer of the bladder. Which assessment data warrant notification of the HCP by the nurse?
- A. The client complains of pain at a '3,' 30 minutes after being medicated.
- B. The client complains it hurts to cough and deep breathe.
- C. The client ambulates to the end of the hall and back before lunch.
- D. The client is lying in a fetal position and has a rigid abdomen.
Correct Answer: D
Rationale: A rigid abdomen and fetal position suggest peritonitis or other serious complications (e.g., anastomotic leak) post-ureterosigmoidostomy, requiring immediate HCP notification. Mild pain, coughing discomfort, and ambulation are less urgent.