Nokea
Which information indicates to the nurse the client teaching about treatment of urinary incontinence has been effective?
- A. The client prepares a scheduled voiding plan.
- B. The client verbalizes the need to increase fluid intake.
- C. The client explains how to perform pelvic floor exercises.
- D. The client attempts to retain the vaginal cone in place the entire day.
Correct Answer: C
Rationale: Pelvic floor (Kegel) exercises strengthen muscles to reduce incontinence, indicating effective teaching. Scheduled voiding is a strategy, increased fluids may worsen incontinence, and vaginal cones are not used all day.
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Which nursing intervention promotes the spontaneous passage of ureteral stones?
- A. Encouraging ambulation as tolerated
- B. Restricting fluid intake
- C. Administering diuretics
- D. Keeping the client on bed rest
Correct Answer: A
Rationale: Encouraging ambulation promotes gravity-assisted stone movement through the ureter, facilitating spontaneous passage.
Which information regarding the care of a cutaneous ileal conduit should the nurse discuss with the client?
- A. Teach the client to instill a few drops of vinegar into the pouch.
- B. Tell the client the stoma should be slightly dusky colored.
- C. Inform the client large clumps of mucus are expected.
- D. Tell the client it is normal for the urine to be pink or red in color.
Correct Answer: C
Rationale: Mucus in the urine is expected with an ileal conduit due to intestinal mucosa in the conduit. Vinegar instillation is not standard, a dusky stoma indicates ischemia, and pink/red urine suggests bleeding, which is abnormal.
The client diagnosed with renal calculi is admitted to the medical unit. Which intervention should the nurse implement first?
- A. Monitor the client’s urinary output.
- B. Assess the client’s pain and rule out complications.
- C. Increase the client’s oral fluid intake.
- D. Use a safety gait belt when ambulating the client.
Correct Answer: B
Rationale: Severe pain is a hallmark of renal calculi, and complications like obstruction or infection must be ruled out first. Pain assessment guides treatment. Monitoring output, increasing fluids, and using a gait belt are secondary.
The nurse caring for a client diagnosed with CKD writes a client problem of 'noncompliance with dietary restrictions.' Which intervention should be included in the plan of care?
- A. Teach the client the proper diet to eat while undergoing dialysis.
- B. Refer the client and significant other to the dietitian.
- C. Explain the importance of eating the proper foods.
- D. Determine the reason for the client not adhering to the diet.
Correct Answer: D
Rationale: Determining the reason for noncompliance (e.g., lack of understanding, financial barriers) is the first step to tailor interventions effectively. Teaching, referrals, or explaining importance are secondary until the root cause is identified.
The nurse observes red urine and several large clots in the tubing of the normal saline continuous irrigation catheter for the client who is one (1) day postoperative TURP. Which intervention should the nurse implement?
- A. Remove the indwelling catheter.
- B. Titrate the NS irrigation to run faster.
- C. Administer protamine sulfate IVP.
- D. Administer vitamin K slowly.
Correct Answer: B
Rationale: Red urine and clots indicate bleeding. Increasing the irrigation rate clears clots and prevents catheter obstruction. Removing the catheter is premature, and protamine/vitamin K are for anticoagulant reversal, not surgical bleeding.