Nokea
Which outcome should the nurse identify for the client diagnosed with fluid volume excess?
- A. The client will void a minimum of 30 mL per hour.
- B. The client will have elastic skin turgor.
- C. The client will have no adventitious breath sounds.
- D. The client will have a serum creatinine of 1.4 mg/dL.
Correct Answer: C
Rationale: No adventitious breath sounds (e.g., crackles) indicates resolution of pulmonary edema from fluid volume excess. Adequate urine output and elastic skin turgor are normal but not specific, and creatinine reflects renal function, not fluid status.
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When asked about factors that are linked to bladder cancer, the nurse correctly identifies which factors? Select all that apply.
- A. Stress incontinence
- B. Frequent intercourse
- C. Sexual promiscuity
- D. Cigarette smoking
- E. History of prostate cancer
- F. Exposure to asbestos
Correct Answer: D
Rationale: Cigarette smoking is a well-established risk factor for bladder cancer.
The nurse is teaching the female client diagnosed with tuberculosis of the urinary tract prior to discharge. Which information should the nurse include specific to this diagnosis?
- A. Instruct the client to take the medication with food.
- B. Explain condoms should be used during treatment.
- C. Discuss the need for follow-up chest x-rays.
- D. Encourage a well-balanced diet and fluid intake.
Correct Answer: B
Rationale: Urinary TB can spread to sexual partners, so condoms are recommended during treatment. Medication timing, chest x-rays (for pulmonary TB), and diet/fluids are general or less specific.
Which statements made by a diabetic client at the clinic strongly suggest that the client has a urinary tract infection? Select all that apply.
- A. I need to urinate frequently.
- B. I can't hold my urine.
- C. I have a burning sensation when I urinate.
- D. I have a burning sensation when I urinate.
- E. I pass a large quantity of urine.
- F. My urine is foul-smelling.
Correct Answer: A,B,C,F
Rationale: Frequent urination, inability to hold urine, burning sensation, and foul-smelling urine are classic symptoms of a urinary tract infection.
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.
The client diagnosed with cancer of the bladder states, 'I have young children. I am too young to die.' Which statement is the nurse’s best response?
- A. This cancer is treatable and you should not give up.'
- B. Cancer occurs at any age. It is just one of those things.'
- C. You are afraid of dying and what will happen to your children.'
- D. Have you talked to your children about your dying?'
Correct Answer: C
Rationale: Reflecting the client’s fear of dying and concern for their children validates emotions and encourages dialogue. Reassurance, generalizing cancer, or prompting child discussions may dismiss the client’s feelings.