Nokea
Which nursing action is most appropriate when preparing the client with an ileal conduit for discharge?
- A. Teach the client how to apply and empty the pouch.
- B. Provide a list of high-sodium foods to avoid.
- C. Instruct the client to restrict fluid intake.
- D. Encourage the client to sleep on the stoma side.
Correct Answer: A
Rationale: Teaching the client to apply and empty the pouch promotes independence and proper stoma care post-discharge.
You may also like to solve these questions
The nurse is caring for a client diagnosed with rule-out nephrotic syndrome. Which intervention should be included in the plan of care?
- A. Monitor the urine for bright-red bleeding.
- B. Evaluate the calorie count of the 500-mg protein diet.
- C. Assess the client’s sacrum for dependent edema.
- D. Monitor for a high serum albumin level.
Correct Answer: C
Rationale: Nephrotic syndrome is characterized by massive proteinuria, hypoalbuminemia, and edema, often dependent (e.g., in the sacrum in bedridden clients). Assessing for dependent edema is a key intervention to monitor disease progression or response to treatment. Bright-red bleeding is not typical, a 500-mg protein diet is incorrect, and high serum albumin is not expected.
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.
When the client asks about the source of donated kidneys, the nurse correctly identifies which of the following as the preferred donor?
- A. A additional peritoneal human
- B. A sibling or living relative
- C. An unrelated living human
- D. A chimpanzee or other primate
Correct Answer: B
Rationale: A sibling or living relative is preferred due to better histocompatibility, reducing the risk of rejection.
Because of the client's impaired urine elimination, which potential skin problem will require additional team planning?
- A. Reduced perspiration
- B. Extreme oiliness
- C. Loss of skin turgor
- D. Pronounced itching
Correct Answer: D
Rationale: Pronounced itching is a common skin problem in renal failure due to uremia and phosphate accumulation.
The nurse is discharging a client with a healthcare facility acquired urinary tract infection. Which information should the nurse include in the discharge teaching?
- A. Limit fluid intake so the urinary tract can heal.
- B. Collect a routine urine specimen for culture.
- C. Take all the antibiotics as prescribed.
- D. Tell the client to void every five (5) to six (6) hours.
Correct Answer: C
Rationale: Completing the full course of antibiotics prevents recurrence and resistance in UTIs. Limiting fluids increases infection risk, routine cultures are unnecessary, and voiding every 2–3 hours is preferred.