Nokea
Which intervention should the nurse include when assessing the client for urinary retention? Select all that apply.
- A. Inquire if the client has the sensation of fullness.
- B. Percuss the suprapubic region for a dull sound.
- C. Scan the bladder with the ultrasound scanner.
- D. Palpate from the umbilicus to the suprapubic area.
- E. Auscultate the two (2) lower abdominal quadrants.
Correct Answer: A,B,C,D
Rationale: Assessing urinary retention involves asking about fullness, percussing for dullness (indicating a full bladder), scanning with ultrasound for residual urine, and palpating for a distended bladder. Auscultation is not relevant.
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To avoid erroneous test results caused by the manipulation of the prostate, the nurse should be included in diagnostic test before the client's rectal examination?
- A. Kidneys, ureters, bladder X-ray
- B. Needle biopsy of the prostate gland
- C. Prostate specific antigen (PSA) test
- D. Transrectal ultrasound examination
Correct Answer: C
Rationale: The PSA test should be done before rectal examination, as manipulation can elevate PSA levels, leading to false results.
The nurse is preparing the plan of care for a client with fluid volume deficit. Which interventions should the nurse include in the plan of care? Select all that apply.
- A. Monitor vital signs every two (2) hours until stable.
- B. Monitor the client’s oral intake and urinary output daily.
- C. Administer mouth care when bathing the client.
- D. Weigh the client weekly in the same clothing at the same time.
- E. Assess skin turgor and mucous membranes every shift.
Correct Answer: A,B,E
Rationale: For fluid volume deficit, monitor vital signs frequently for stability, track intake/output daily to assess hydration, and assess skin turgor/mucous membranes for dehydration. Weekly weights are too infrequent, and mouth care during bathing is not specific.
Which finding provides the best evidence that peritoneal dialysis is achieving a therapeutic effect?
- A. Urine output increases.
- B. Appetite improves.
- C. Red blood cell count is lower.
Correct Answer: B
Rationale: Improved appetite indicates reduced uremia, a sign that dialysis is effectively removing toxins.
The nurse and an unlicensed assistive personnel (UAP) are caring for a group of clients. Which nursing intervention should the nurse perform?
- A. Measure the client’s output from the indwelling catheter.
- B. Record the client’s intake and output on the I&O sheet.
- C. Instruct the client on appropriate fluid restrictions.
- D. Provide water for a client diagnosed with diabetes insipidus.
Correct Answer: C
Rationale: Instructing on fluid restrictions requires nursing judgment and education skills, which are outside the UAP’s scope. Measuring output, recording I&O, and providing water are delegable tasks.
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.