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Which nursing intervention is most appropriate when the nurse is changing the appliance of the client's ileal conduit?
- A. When you remove the appliance, let the urine drip into a container.
- B. When you remove the appliance, insert a tampon into the stoma.
- C. When you remove the appliance, press a gloved finger over the stoma.
- D. When you remove the appliance, pinch the stoma with two fingers.
Correct Answer: C
Rationale: Pressing a gloved finger over the stoma prevents urine leakage during appliance changes, maintaining hygiene and skin integrity.
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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.
Considering the amount of time the client must remain in bed, why is it imperative for the nurse to monitor for a urinary tract infection?
- A. The client will not be able to complete hygiene needs.
- B. The client will not be able to fully empty the bladder.
- C. The client will not be able to maintain bladder control.
- D. The client will not be able to drink sufficient fluids.
Correct Answer: B
Rationale: Prolonged bed rest can lead to incomplete bladder emptying, increasing the risk of urinary stasis and subsequent urinary tract infections.
When preparing the client for catheterization, how should the nurse position the client?
- A. Lithotomy position
- B. Recumbent
- C. Knee-chest position
- D. Prone
Correct Answer: A
Rationale: The lithotomy position provides optimal access to the urethral meatus for catheterization in female clients.
The nurse is preparing the plan of care for the client diagnosed with a neurogenic flaccid bladder. Which expected outcome is appropriate for this client?
- A. The client has conscious control over bladder activity.
- B. The client’s bladder does not become overdistended.
- C. The client has bladder sensation and no discomfort.
- D. The client demonstrates how to check for bladder distention.
Correct Answer: B
Rationale: A neurogenic flaccid bladder lacks tone, risking overdistention. Preventing this is a key outcome to avoid complications like infection or reflux. Conscious control and sensation are unlikely, and checking distention is an intervention.
The nurse is caring for the client recovering from a percutaneous renal biopsy. Which data indicate the client is complying with client teaching?
- A. The client is lying flat in the saline position.
- B. The client continues oral fluids restriction while on bedrest.
- C. The client uses the bedside commode to urinate.
- D. The client refuses to ask for any pain medication.
Correct Answer: A
Rationale: Post-renal biopsy, lying flat (supine, assuming 'saline' is a typo) prevents bleeding complications, indicating compliance. Fluid restriction is unnecessary, using a commode risks bleeding, and refusing pain meds is unrelated.