Nokea
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.
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The UAP tells the nurse the client with ARF has a white crystal-like layer on top of the skin. Which intervention should the nurse implement?
- A. Have the assistant apply a moisture barrier cream to the skin.
- B. Instruct the UAP to bathe the client in cool water.
- C. Tell the UAP not to turn the client in this condition.
- D. Explain this is normal and do not do anything for the client.
Correct Answer: D
Rationale: The white crystal-like layer is uremic frost, a result of urea crystallizing on the skin due to severe uremia in ARF. This is an expected finding and requires no specific intervention beyond routine skin care and dialysis to address uremia.
If this client is typical of others who acquire bladder cancer, which symptoms are most likely to have manifested in the early stage of this disease? Select all that apply.
- A. Difficulty voiding
- B. Persistent oliguria
- C. Painless hematuria
- D. Urethral discharge
- E. Painful urination
- F. Postvoid dribbling
Correct Answer: C
Rationale: Painless hematuria is the most common early symptom of bladder cancer.
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.
After inserting an indwelling catheter into a male client, which technique is most appropriate for stabilizing the catheter to avoid damage to the penis?
- A. Tape the catheter to the abdomen.
- B. Pass the catheter under the client's leg.
- C. Fasten the drainage tubing to the bed with a safety pin.
- D. I'm very the catheter into the tubing of a collecting bag.
Correct Answer: A
Rationale: Taping the catheter to the abdomen stabilizes it without causing traction or damage to the penis, promoting comfort and safety.
Which assessment before and after peritoneal dialysis is most valuable in evaluating the outcome of treatment?
- A. Pulse rate
- B. Body weight
- C. A Abdominal girth
- D. Urine output
Correct Answer: B
Rationale: Body weight is the most valuable assessment, as weight loss after dialysis indicates effective removal of excess fluid.