Nokea
Which nursing action is most appropriate when the client complains about being thirsty because of the fluid restrictions?
- A. Giving the client hard candy to suck
- B. Providing the client with ice chips
- C. Offering the client an ice cream bar
- D. Supplying the client with fresh fruit
Correct Answer: A
Rationale: Hard candy stimulates saliva production, alleviating thirst without contributing to fluid intake, which is restricted.
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The client diagnosed with cancer of the bladder is scheduled to have a cutaneous urinary diversion procedure. Which preoperative teaching intervention specific to the procedure should be included?
- A. Demonstrate turn, cough, and deep breathing.
- B. Explain a bag will drain the urine from now on.
- C. Instruct the client on the use of a PCA pump.
- D. Take the client to the ICD so the client can become familiar with it.
Correct Answer: B
Rationale: A cutaneous urinary diversion (e.g., ileal conduit) requires a stoma and drainage bag. Explaining this prepares the client for post-op care. Coughing/breathing, PCA use, and ICU visits are general, not specific.
The nurse is developing a care map to care for a client diagnosed with chronic renal failure (CRF) on hemodialysis. Which interrelated concepts should be included in the map? Select all that apply.
- A. Fluid and electrolytes.
- B. Hematologic regulation.
- C. Digestion.
- D. Metabolism.
- E. Mobility.
- F. Nutrition.
Correct Answer: A,B,D,F
Rationale: CRF affects fluid/electrolyte balance (impaired excretion), hematologic regulation (anemia from low erythropoietin), metabolism (altered drug clearance), and nutrition (dietary restrictions). Digestion and mobility are less directly impacted.
The client is one (1) day postoperative TURP. Which task should the nurse delegate to the UAP?
- A. Increase the irrigation fluid to clear clots from the tubing.
- B. Elevate the scrotum on a towel roll for support.
- C. Change the dressing on the first postoperative day.
- D. Teach the client how to care for the continuous irrigation catheter.
Correct Answer: B
Rationale: Elevating the scrotum is a simple supportive task within the UAP’s scope. Adjusting irrigation, changing dressings, and teaching require nursing judgment and are not delegable.
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.
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.