Nokea
Which intervention should the nurse implement when caring for the client with a nephrostomy tube?
- A. Change the dressing only if soiled by urine.
- B. Clean the end of the connecting tubing with Betadine.
- C. Clean the drainage system every day with bleach and water.
- D. Assess the tube for kinks to prevent obstruction.
Correct Answer: D
Rationale: Assessing for kinks ensures patency of the nephrostomy tube, preventing urine backup and complications. Dressings are changed regularly, Betadine is not used for tubing, and bleach cleaning is inappropriate.
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Which statements made by the client's spouse most closely correlate with the diagnosis of acute glomerulonephritis? Select all that apply.
- A. My spouse's face looks rather puffy lately.
- B. Recently my spouse has been quite forgetful.
- C. My spouse has been salting food heavily.
- D. My spouse has been eating very well.
- E. My spouse hasn't been eating very well.
- F. My spouse gets up at night to use the bathroom.
Correct Answer: A,F
Rationale: Facial puffiness and nocturia are symptoms of glomerulonephritis, reflecting fluid retention and impaired kidney function.
Which of the following findings is the most significant information to report when caring for a client undergoing peritoneal dialysis?
- A. Loss of body weight
- B. Decreased serum creatinine
- C. Elevated body temperature
- D. Output that exceeds intake
Correct Answer: C
Rationale: An elevated body temperature may indicate infection, a serious complication of peritoneal dialysis, and must be reported.
The nurse is developing a plan of care for a client diagnosed with ARF. Which statement is an appropriate outcome for the client?
- A. Monitor intake and output every shift.
- B. Decrease of pain by three (3) levels on a 1-to-10 scale.
- C. Electrolytes are within normal limits.
- D. Administer enemas to decrease hyperkalemia.
Correct Answer: C
Rationale: An appropriate outcome for ARF is achieving normal electrolyte levels, as imbalances like hyperkalemia are common. Monitoring intake/output and administering enemas are interventions, not outcomes, and pain reduction is less specific to ARF.
As the nurse instructs the client about CBI, which information should the nurse provide? Select all that apply.
- A. You may feel the urge to urinate even though the bladder is empty.
- B. Do not to try to urinate around the catheter, because this will cause bladder spasms.
- C. You need to limit your fluids to 4 glasses per day.
- D. It is normal for the urine to be bloody immediately after surgery.
- E. The catheter will be removed in about a week.
- F. By the time you are ready to go home, your urine should be pink with a few clots.
Correct Answer: A,B,D,F
Rationale: These statements accurately describe CBI effects, expectations, and precautions post-TURP.
The nurse is inserting an indwelling catheter into a female client. Which interventions should be implemented? Rank in the order of performance.
- A. Explain the procedure to the client.
- B. Set up the sterile field.
- C. Inflate the catheter bulb.
- D. Place absorbent pads under the client.
- E. Clean the perineum from clean to dirty with Betadine.
Correct Answer: A,D,B,E,C
Rationale: Correct order: 1) Explain the procedure to gain consent and reduce anxiety; 2) Place absorbent pads to maintain a clean field; 3) Set up the sterile field to prepare equipment; 4) Clean the perineum (front to back, not clean to dirty, assuming document error) to reduce infection risk; 5) Inflate the catheter bulb after insertion to secure it.