Nokea
Which nursing intervention is most important to add to the client's care plan after removal of the suprapubic catheter?
- A. Check the client's urine specific gravity every shift.
- B. Measure the client's abdominal girth daily.
- C. Change wet abdominal dressings as needed.
- D. Perform a credé maneuver every 4 hours.
Correct Answer: C
Rationale: Changing wet dressings prevents infection and promotes healing at the suprapubic site.
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The nurse is preparing a teaching care plan for the client diagnosed with nephrotic syndrome. Which intervention should the nurse include?
- A. Stop steroids if a moon face develops.
- B. Provide teaching for taking diuretics.
- C. Increase the intake of dietary sodium.
- D. Report a decrease in daily weight.
Correct Answer: B
Rationale: Diuretics are commonly prescribed in nephrotic syndrome to manage edema. Teaching proper diuretic use (e.g., timing, side effects like hypokalemia) is essential. Stopping steroids for moon face is incorrect, increasing sodium worsens edema, and weight loss is expected, not a concern.
The client diagnosed with a urinary tract infection has a blood pressure of 83/56 mm Hg and a pulse of 122 bpm. Which should the nurse implement first?
- A. Notify the health-care provider (HCP).
- B. Hang the IVPB antibiotic at the prescribed rate.
- C. Check the laboratory work to determine if the urine culture has been completed.
- D. Increase the normal saline IV fluids from keep open to 150 mL/hour on the IV pump.
Correct Answer: D
Rationale: Hypotension (83/56) and tachycardia (122 bpm) suggest septic shock from the UTI. Increasing IV fluids to 150 mL/hour improves perfusion, stabilizing the client. Notification, antibiotics, and lab checks are secondary to immediate fluid resuscitation.
The client diagnosed with renal calculi is admitted to the medical unit. Which intervention should the nurse implement first?
- A. Monitor the client’s urinary output.
- B. Assess the client’s pain and rule out complications.
- C. Increase the client’s oral fluid intake.
- D. Use a safety gait belt when ambulating the client.
Correct Answer: B
Rationale: Severe pain is a hallmark of renal calculi, and complications like obstruction or infection must be ruled out first. Pain assessment guides treatment. Monitoring output, increasing fluids, and using a gait belt are secondary.
Before peritoneal dialysis begins, the nurse correctly informs the client that the procedure involves the movement of urea and creatinine through the peritoneum by which means?
- A. Osmosis
- B. Diffusion
- C. Filtration
- D. Gravity
Correct Answer: B
Rationale: Diffusion is the primary mechanism by which urea and creatinine move across the peritoneal membrane during dialysis.
Which information regarding the care of a cutaneous ileal conduit should the nurse discuss with the client?
- A. Teach the client to instill a few drops of vinegar into the pouch.
- B. Tell the client the stoma should be slightly dusky colored.
- C. Inform the client large clumps of mucus are expected.
- D. Tell the client it is normal for the urine to be pink or red in color.
Correct Answer: C
Rationale: Mucus in the urine is expected with an ileal conduit due to intestinal mucosa in the conduit. Vinegar instillation is not standard, a dusky stoma indicates ischemia, and pink/red urine suggests bleeding, which is abnormal.