Nokea
Which nursing assessment is essential to add to the client's care plan?
- A. Monitor body temperature.
- B. Measure intake and output.
- C. Assess for urine retention.
- D. Check the urine for glucose.
Correct Answer: B
Rationale: Measuring intake and output is critical in renal failure to monitor fluid balance and kidney function.
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The client is 12 hours postoperative renal surgery. Which data warrant immediate intervention by the nurse?
- A. The abdomen is soft, nontender, and rounded.
- B. Pain is not felt with dorsal flexion of the foot.
- C. The urine output is 60 mL for the past two (2) hours.
- D. The client’s trough vancomycin level is 24 mcg/mL.
Correct Answer: D
Rationale: A vancomycin level of 24 mcg/mL is above the therapeutic range (10–20 mcg/mL), risking nephrotoxicity, especially post-renal surgery. Soft abdomen, no pain on dorsiflexion, and 60 mL urine output are normal.
The female client in an outpatient clinic is being sent home with a diagnosis of urinary tract infection (UTI). Which instruction should the nurse teach to prevent a recurrence of a UTI?
- A. Clean the perineum from back to front after a bowel movement.
- B. Take warm tub baths instead of hot showers daily.
- C. Void immediately preceding sexual intercourse.
- D. Avoid coffee, tea, colas, and alcoholic beverages.
Correct Answer: D
Rationale: Avoiding bladder irritants like coffee, tea, colas, and alcohol reduces UTI recurrence risk. Wiping back to front increases infection risk, tub baths are less effective than showers, and voiding before intercourse is less critical than after.
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.
Which problem is the nurse's immediate concern after kidney transplant surgery?
- A. Risk for infection
- B. Fluid overload
- C. Hypotension
- D. Pain management
Correct Answer: A
Rationale: Risk for infection is the immediate concern post-transplant due to immunosuppression, which increases susceptibility to infections.
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.