Nokea
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.
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Which recommendations by the nurse are most effective in reducing bacterial growth in a female client's bladder? Select all that apply.
- A. Drink a large quantity of fluids.
- B. Change underclothing each day.
- C. Avoid the use of public restrooms.
- D. Use only white toilet tissue.
- E. Urinate after having sexual intercourse.
- F. Drink fluids that are highly acidic.
Correct Answer: A,E
Rationale: Drinking plenty of fluids promotes urine flow, flushing bacteria from the bladder, and urinating after intercourse helps remove bacteria introduced during sexual activity.
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.
On the basis of the nurse's knowledge of patient rights, which Federal law has the PCT violated?
- A. Good samarian Act
- B. Uncontractic Oath
- C. Health Insurance Portability and Accountability Act (HIPAA)
- D. Emergency Medical Treatment and Liability Act (EMTALA)
Correct Answer: C
Rationale: The PCT violated HIPAA by discussing the client's condition loudly in a public area, compromising patient confidentiality.
The client diagnosed with CKD has a new arteriovenous fistula in the left forearm. Which intervention should the nurse implement?
- A. Teach the client to carry heavy objects with the right arm.
- B. Perform all laboratory blood tests on the left arm.
- C. Instruct the client to lie on the left arm during the night.
- D. Discuss the importance of not performing any hand exercises.
Correct Answer: A
Rationale: To protect the new AV fistula, the client should avoid stress on the left arm. Carrying heavy objects with the right arm prevents fistula damage. Blood tests should avoid the fistula arm, lying on it risks compression, and hand exercises are encouraged to promote fistula maturation.
Which nursing intervention is most important to add to the client's care plan after removal of the suprapubic catheter?
- A. Check the client's urine specific gravity every shift.
- B. Measure the client's abdominal girth daily.
- C. Change wet abdominal dressings as needed.
- D. Perform a credé maneuver every 4 hours.
Correct Answer: C
Rationale: Changing wet dressings prevents infection and promotes healing at the suprapubic site.