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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.
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The client receiving hemodialysis is being discharged home from the dialysis center. Which instruction should the nurse teach the client?
- A. Notify the HCP if oral temperature is 102°F or greater.
- B. Apply ice to the access site if it starts bleeding at home.
- C. Keep fingernails short and try not to scratch the skin.
- D. Encourage the significant other to make decisions for the client.
Correct Answer: A
Rationale: A fever of 102°F or higher may indicate infection, a serious complication in hemodialysis patients, requiring prompt HCP notification. Ice may worsen bleeding, short nails are general advice, and encouraging dependency is not therapeutic.
The elderly client recovering from a prostatectomy has been experiencing stress incontinence. Which independent nursing intervention should the nurse discuss with the client?
- A. Establish a set voiding frequency of every two (2) hours while awake.
- B. Encourage a family member to assist the client to the bathroom to void.
- C. Apply a transurethral electrical stimulator to relieve symptoms of urinary urgency.
- D. Discuss the use of a 'bladder drill,' including a timed voiding schedule.
Correct Answer: D
Rationale: A bladder drill with timed voiding strengthens bladder control and reduces stress incontinence post-prostatectomy. Voiding every 2 hours is part of it, family assistance reduces independence, and electrical stimulators are not standard.
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 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.
When managing catheter care, which nursing action is most important for promoting wound healing?
- A. Avoid tension on the catheter.
- B. Encourage oral fluid intake.
- C. Clean the urethral meatus daily.
- D. Clamp and release the catheter every 2 hours.
Correct Answer: A
Rationale: Avoiding tension on the catheter prevents trauma to the surgical site, promoting healing.