Nokea
Which response by the nurse is most appropriate?
- A. His bladder retraining is coming along, and before long he will be urinating like normal.
- B. He seems to have more incontinence in the afternoon and evening.
- C. In order to protect his privacy, I can't give you that information.
- D. Bladder retraining is slow work. We have to take him to the toilet every 2 hours.
Correct Answer: C
Rationale: To comply with HIPAA, the nurse must protect the client's privacy and not disclose health information without consent, making this the most appropriate response.
You may also like to solve these questions
Before administering an analgesic to the client, which information is most important for the nurse to assess?
- A. Whether the urine is bloody
- B. Whether the client has been up walking in the room
- C. Whether the catheter is draining urine
- D. Whether the client has been drinking adequate fluids
Correct Answer: C
Rationale: Ensuring the catheter is draining urine is critical to prevent bladder distention, which could exacerbate discomfort.
The nurse identifies the concepts of elimination and immunity for a female client diagnosing with a urinary tract infection. Which discharge instructions should the nurse provide the client? Select all that apply.
- A. Teach the client to wipe from front to back after voiding.
- B. Encourage the client to drink cranberry juice each morning.
- C. Inform the client that frequent episodes of incontinence are expected.
- D. Discuss the signs and symptoms of a recurrent infection.
- E. Have the client fill a container of water to sip until at least 2,000 mL is consumed.
- F. Request that the client sit in a tub of warm water twice a day for 25 minutes.
Correct Answer: A,B,D,E
Rationale: Wiping front to back prevents bacterial spread, cranberry juice may reduce UTI risk, discussing recurrent symptoms aids early detection, and 2,000 mL fluid intake flushes the bladder. Incontinence is not expected, and tub baths increase infection risk.
Which statement by the client with an ileal conduit indicates a need for further teaching?
- A. I will change the pouch every 5 to 7 days.
- B. I will keep the skin around the stoma clean and dry.
- C. I will empty the pouch when it is one-third full.
- D. I will avoid drinking fluids to reduce urine output.
Correct Answer: D
Rationale: Avoiding fluids is incorrect, as adequate fluid intake is necessary to maintain urine flow and prevent complications.
Which nursing assessment is essential to add to the client's care plan?
- A. Monitor body temperature.
- B. Measure intake and output.
- C. Assess for urine retention.
- D. Check the urine for glucose.
Correct Answer: B
Rationale: Measuring intake and output is critical in renal failure to monitor fluid balance and kidney function.
The male client diagnosed with CKD has received the initial dose of erythropoietin, a biologic response modifier, one (1) week ago. Which complaint by the client indicates the need to notify the health-care provider?
- A. The client complains of flu-like symptoms.
- B. The client complains of being tired all the time.
- C. The client reports an elevation in his blood pressure.
- D. The client reports discomfort in his legs and back.
Correct Answer: C
Rationale: Erythropoietin can cause hypertension as a side effect, which is significant in CKD patients and warrants notifying the provider. Flu-like symptoms and fatigue are common and expected, while leg/back discomfort is less specific.