Nokea
Which nursing assessment is most important to perform regularly when a client has an arteriovenous fistula?
- A. Checking the color and temperature of the client's hand
- B. Monitoring the client's wrist and finger range of motion
- C. Improving the tone and coordination of the client's arm muscles
- D. Inspecting the client's forearm skin turgor
Correct Answer: A
Rationale: Checking the color and temperature of the hand ensures adequate blood flow and detects complications like thrombosis in the arteriovenous fistula.
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Which symptom indicative of renal failure would the nurse expect to note when assessing this client?
- A. Anemia
- B. Hypotension
- C. Weight loss
- D. Fever
Correct Answer: A
Rationale: Anemia is a common symptom of renal failure due to decreased erythropoietin production by the kidneys.
The client with a TURP who has a continuous irrigation catheter complains of the need to urinate. Which intervention should the nurse implement first?
- A. Call the surgeon to inform the HCP of the client’s complaint.
- B. Administer the client a narcotic medication for pain.
- C. Explain to the client this sensation happens frequently.
- D. Assess the continuous irrigation catheter for patency.
Correct Answer: D
Rationale: The urge to urinate may indicate a blocked catheter due to clots. Assessing patency ensures proper function and addresses the cause. Explaining the sensation, notifying the surgeon, or giving narcotics are secondary.
The client is diagnosed with a uric acid stone. Which foods should the client eliminate from the diet to help prevent reoccurrence?
- A. Beer and colas.
- B. Asparagus and cabbage.
- C. Venison and sardines.
- D. Cheese and eggs.
Correct Answer: C
Rationale: Uric acid stones are linked to high purine intake. Venison and sardines are high-purine foods, increasing uric acid production. Beer/colas affect hydration, asparagus/cabbage are low-purine, and cheese/eggs are less relevant.
Which response by the nurse is best?
- A. Encourage the client to restrict fluid intake because it shows evidence of client cooperation.
- B. Encourage the client to restrict fluid intake because it leads to accomplishing the goal.
- C. Discourage the client from restricting fluid intake because it contributes to constipation.
- D. Discourage the client from restricting fluid intake because it potentiates fluid imbalance.
Correct Answer: D
Rationale: Restricting fluid intake can lead to dehydration and fluid imbalance, which can worsen health outcomes, so the nurse should discourage this action.
The nurse is preparing the discharge teaching plan for the male client with a left-sided nephrectomy. Which statement indicates the teaching is effective?
- A. I can’t wait to start back to work next week, I really need the money.
- B. I will take my temperature and if it is above 101 I will call my doctor.
- C. I am glad I won’t have to keep track of how much I urinate in the day.
- D. I am happy I will be able eat what I usually eat, I don’t like this food.
Correct Answer: B
Rationale: Effective discharge teaching post-nephrectomy includes recognizing signs of infection, such as fever above 101°F, requiring prompt reporting. Returning to work too soon, not monitoring urine output, or resuming a normal diet may be incorrect.