Nokea
Which nursing assessment is most important before beginning bladder retraining for this client?
- A. Recording the times at which the client is incontinent
- B. Checking the specific gravity of the urine
- C. Beginning the client's incontinence pad
Correct Answer: A
Rationale: Recording the times of incontinence helps establish a pattern, which is critical for developing an effective bladder retraining schedule tailored to the client's needs.
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The nurse is assessing a client diagnosed with urethral strictures. Which data support the diagnosis?
- A. Complaints of frequency and urgency.
- B. Clear yellow drainage from the urethra.
- C. Complaints of burning during urination.
- D. A diminished force and stream during voiding.
Correct Answer: D
Rationale: Urethral strictures obstruct urine flow, causing a diminished force and stream. Frequency, urgency, and burning suggest UTI, and clear drainage is unrelated.
Which information should the nurse include when explaining the management of the client's urolithiasis? Select all that apply.
- A. Increase fluid intake to 3 liters per day.
- B. Strain all urine to collect stones for analysis.
- C. Take prescribed analgesics for pain relief.
- D. Avoid all dairy products to prevent stone formation.
- E. Follow a low-sodium diet to reduce stone risk.
- F. Report fever or chills immediately.
Correct Answer: A,B,C,F
Rationale: Increasing fluid intake, straining urine, taking analgesics, and reporting fever or chills are key management strategies for urolithiasis to promote stone passage and prevent complications.
Which nursing diagnosis is priority for the client who has undergone a TURP?
- A. Potential for sexual dysfunction.
- B. Potential for an altered body image.
- C. Potential for chronic infection.
- D. Potential for hemorrhage.
Correct Answer: D
Rationale: Hemorrhage is the priority post-TURP due to the risk of significant bleeding from the surgical site, which can be life-threatening. Sexual dysfunction, body image, and infection are secondary concerns.
The client with CKD is placed on a fluid restriction of 1,500 mL/day. On the 7 a.m. to 7 p.m. shift the client drank an eight (8)-ounce cup of coffee, 4 ounces of juice, 12 ounces of tea, and 2 ounces of water with medications. What amount of fluid can the 7 p.m. to 7 a.m. nurse give to the client?
Correct Answer: 720 mL
Rationale: Convert ounces to mL (1 oz ≈ 30 mL): Coffee: 8 oz = 240 mL, Juice: 4 oz = 120 mL, Tea: 12 oz = 360 mL, Water: 2 oz = 60 mL. Total consumed: 240 + 120 + 360 + 60 = 780 mL. Daily limit: 1,500 mL. Remaining: 1,500 - 780 = 720 mL.
When performing a physical assessment, which sensation would the nurse expect to detect when palpating the site of the arteriovenous fistula?
- A. A pulse
- B. A bruit
- C. A thrill
- D. A click
Correct Answer: C
Rationale: A thrill, a buzzing sensation, is expected when palpating a functioning arteriovenous fistula, indicating proper blood flow.