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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.
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The nurse performs bladder irrigation through an indwelling catheter. The nurse instilled 90 mL of sterile normal saline. The catheter drained 710 mL. What is the client’s output?
Correct Answer: 620 mL
Rationale: Urine output = Total drainage - Irrigation fluid instilled = 710 mL - 90 mL = 620 mL. This isolates the client’s actual urine production from the irrigation fluid.
If this client is typical of others who acquire bladder cancer, which symptoms are most likely to have manifested in the early stage of this disease? Select all that apply.
- A. Difficulty voiding
- B. Persistent oliguria
- C. Painless hematuria
- D. Urethral discharge
- E. Painful urination
- F. Postvoid dribbling
Correct Answer: C
Rationale: Painless hematuria is the most common early symptom of bladder cancer.
A nurse is assigned to care for a client with a cutaneous ureterostomy. Which of the following images correlates with the client's urinary diversion?
- A. Image A
- B. Image B
- C. Image C
- D. Image D
Correct Answer: C
Rationale: A cutaneous ureterostomy involves the ureters being brought to the skin surface, typically depicted as a stoma on the abdomen, which corresponds to a specific image (assumed as C based on standard depictions).
Which assessment before and after peritoneal dialysis is most valuable in evaluating the outcome of treatment?
- A. Pulse rate
- B. Body weight
- C. A Abdominal girth
- D. Urine output
Correct Answer: B
Rationale: Body weight is the most valuable assessment, as weight loss after dialysis indicates effective removal of excess fluid.
The client who is post-thyroidectomy complains of numbness and tingling around the mouth and the tips of the fingers. Which intervention should the nurse implement first?
- A. Notify the health-care provider immediately.
- B. Tap the cheek about two (2) cm anterior to the earlobe.
- C. Check the serum calcium and magnesium levels.
- D. Prepare to administer calcium gluconate IVP.
Correct Answer: C
Rationale: Numbness and tingling post-thyroidectomy suggest hypocalcemia due to parathyroid injury. Checking serum calcium and magnesium levels confirms the diagnosis before treatment. Notification, Chvostek’s sign, or calcium administration follow confirmation.