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Which intervention is most important for the nurse to implement for the client diagnosed with rule-out renal calculi?
- A. Assess the client’s neurological status every two (2) hours.
- B. Strain all urine and send any sediment to the laboratory.
- C. Monitor the client’s creatinine and BUN levels.
- D. Take a 24-hour dietary recall during the client interview.
Correct Answer: B
Rationale: Straining urine to capture stones or sediment is critical for diagnosing renal calculi, as it confirms the presence and type of stones. Neurological status, lab monitoring, and dietary recall are secondary.
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Which statements should be included when the nurse instructs a female client about the technique for collecting a clean-catch midstream urine specimen for routine urinalysis? Select all that apply.
- A. Clean the urethral area using several circular motions.
- B. Void into the plastic liner under the toilet seat.
- C. Void a small amount, and then collect a sample of urine.
- D. Mix the antiseptic solution with the collected urine specimen.
- E. Collect the urine in the nonsterile cup.
- F. Drink several caffeinated beverages before collecting the urine.
Correct Answer: A,C
Rationale: Cleaning the urethral area and voiding a small amount before collecting the sample ensure a clean-catch specimen, reducing contamination and ensuring accurate results.
The client diagnosed with ARF has a serum potassium level of 6.8 mEq/L. Which collaborative treatment should the nurse anticipate for the client?
- A. Administer a phosphate binder.
- B. Type and crossmatch for whole blood.
- C. Assess the client for leg cramps.
- D. Prepare the client for dialysis.
Correct Answer: D
Rationale: A potassium level of 6.8 mEq/L indicates severe hyperkalemia, which can cause cardiac arrhythmias. Dialysis is the most effective treatment to rapidly lower potassium in ARF. Phosphate binders, blood transfusions, or assessing cramps do not address hyperkalemia directly.
The nurse is preparing the plan of care for the client diagnosed with a neurogenic flaccid bladder. Which expected outcome is appropriate for this client?
- A. The client has conscious control over bladder activity.
- B. The client’s bladder does not become overdistended.
- C. The client has bladder sensation and no discomfort.
- D. The client demonstrates how to check for bladder distention.
Correct Answer: B
Rationale: A neurogenic flaccid bladder lacks tone, risking overdistention. Preventing this is a key outcome to avoid complications like infection or reflux. Conscious control and sensation are unlikely, and checking distention is an intervention.
Which nursing diagnosis is priority for the client who has undergone a TURP?
- A. Potential for sexual dysfunction.
- B. Potential for an altered body image.
- C. Potential for chronic infection.
- D. Potential for hemorrhage.
Correct Answer: D
Rationale: Hemorrhage is the priority post-TURP due to the risk of significant bleeding from the surgical site, which can be life-threatening. Sexual dysfunction, body image, and infection are secondary concerns.
The nurse is planning the care of a postoperative client with an ileal conduit. Which intervention should be included in the plan of care?
- A. Provide meticulous skin care and pouching.
- B. Apply sterile drainage bags daily.
- C. Monitor the pH of the urine weekly.
- D. Assess the stoma site every day.
Correct Answer: A
Rationale: Meticulous skin care and proper pouching prevent skin breakdown and infection around the ileal conduit stoma. Sterile bags are unnecessary, weekly pH monitoring is not standard, and daily stoma assessment is part of skin care.