Nokea
Which menu choice is best for the nurse to recommend?
- A. Hot dog with potato salad
- B. Beef bouillon and crackers
- C. Chicken breast on lettuce
- D. Cheese pizza with thin crust
Correct Answer: C
Rationale: Chicken breast on lettuce is low in sodium, making it suitable for a low-sodium diet required for glomerulonephritis management.
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When applying an external catheter to a male client, which action by the nurse is correct?
- A. I think the nurse is correct applying the catheter.
- B. Measure the length and circumference of the penis.
- C. Leave space between the end of the penis and the catheter's drainage end.
- D. Retract the foreskin before rolling the catheter sheath over the penis.
Correct Answer: C
Rationale: Leaving space between the penis and the catheter's drainage end prevents pressure and irritation, ensuring proper function and comfort.
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.
Which nursing intervention promotes the spontaneous passage of ureteral stones?
- A. Encouraging ambulation as tolerated
- B. Restricting fluid intake
- C. Administering diuretics
- D. Keeping the client on bed rest
Correct Answer: A
Rationale: Encouraging ambulation promotes gravity-assisted stone movement through the ureter, facilitating spontaneous passage.
The nurse is caring for a client with chronic pyelonephritis. Which assessment data support the diagnosis of chronic pyelonephritis?
- A. The client has fever, chills, flank pain, and dysuria.
- B. The client complains of fatigue, headaches, and increased urination.
- C. The client had a group B beta-hemolytic strep infection last week.
- D. The client has an acute viral pneumonia infection.
Correct Answer: B
Rationale: Chronic pyelonephritis presents with subtle symptoms like fatigue, headaches, and polyuria due to long-term renal damage. Acute symptoms (fever, chills) are more typical of acute pyelonephritis. Strep or pneumonia are unrelated.
The client with a history of renal calculi calls the clinic and reports having burning on urination, chills, and an elevated temperature. Which instruction should the nurse discuss with the client?
- A. Increase water intake for the next 24 hours.
- B. Take two (2) Tylenol to help decrease the temperature.
- C. Come to the clinic and provide a urinalysis specimen.
- D. Use a sterile 4×4 gauze to strain the client’s urine.
Correct Answer: C
Rationale: Burning, chills, and fever suggest a UTI, possibly related to calculi. A urinalysis specimen is needed to diagnose and guide treatment. Increasing fluids, taking Tylenol, or straining urine are secondary.