Which statement indicates the client diagnosed with calcium phosphate renal calculi understands the discharge teaching for ways to prevent future calculi formation?
- A. I should increase my fluid intake, especially in warm weather.'
- B. I should eat foods containing cocoa and chocolate.'
- C. I will walk about a mile every week and not exercise often.'
- D. I should take one (1) vitamin a day with extra calcium.'
Correct Answer: A
Rationale: Increased fluid intake dilutes urine, reducing calcium phosphate stone formation, especially in warm weather when dehydration risk is higher. Cocoa/chocolate, minimal exercise, and extra calcium increase stone risk.
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The nurse is discussing how to prioritize care with the UAP. Which client should the nurse instruct the UAP to see first?
- A. The immobile client who needs sequential compression devices removed.
- B. The elderly woman who needs assistance ambulating to the bathroom.
- C. The surgical client who needs help changing the gown after bathing.
- D. The male client who needs the intravenous catheter discontinued.
Correct Answer: B
Rationale: Assisting an elderly woman to the bathroom prevents falls and addresses immediate elimination needs, prioritizing safety. Removing SCDs, changing gowns, and discontinuing IVs are less urgent.
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.
While the fluid is being administered, which nursing assessment is most important?
- A. Checking for pedal edema
- B. Assessing the rapid weight gain
- C. Monitoring specific gravity
- D. Auscultating breath sounds
Correct Answer: D
Rationale: Auscultating breath sounds is critical during a fluid challenge to detect signs of fluid overload, such as pulmonary edema.
The nurse is caring for a client with a TURP. Which expected outcome indicates the client’s condition is improving?
- A. The client is using the maximum amount allowed by the PCA pump.
- B. The client’s bladder spasms are relieved by medication.
- C. The client’s scrotum is swollen and tender with movement.
- D. The client has passed a large, hard, brown stool this morning.
Correct Answer: B
Rationale: Relief of bladder spasms indicates reduced irritation and healing post-TURP. Maximum PCA use, scrotal swelling, or hard stools do not reflect improvement and may indicate complications.
When the client complains about the bland taste of the food, the nurse appropriately recommends substituting salt with which condiment?
- A. Catsup
- B. Mustard
- C. Soy sauce
- D. Lemon juice
Correct Answer: D
Rationale: Lemon juice is a low-sodium flavor enhancer, suitable for a sodium-restricted diet, unlike catsup, mustard, or soy sauce.
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