Nokea
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.
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The client is diagnosed with a uric acid stone. Which foods should the client eliminate from the diet to help prevent reoccurrence?
- A. Beer and colas.
- B. Asparagus and cabbage.
- C. Venison and sardines.
- D. Cheese and eggs.
Correct Answer: C
Rationale: Uric acid stones are linked to high purine intake. Venison and sardines are high-purine foods, increasing uric acid production. Beer/colas affect hydration, asparagus/cabbage are low-purine, and cheese/eggs are less relevant.
When the nurse interviews the client, which symptoms will the client most likely report if a bladder infection has been acquired? Select all that apply.
- A. Sharp flank pain
- B. Uretrail discharge
- C. Strong-smelling urine
- D. Burning on urination
- E. Urgency
- F. Frequency
Correct Answer: C,D,E,F
Rationale: Symptoms of a bladder infection typically include strong-smelling urine, burning on urination, urgency, and frequency, as these reflect irritation and inflammation of the bladder.
Which symptom indicative of renal failure would the nurse expect to note when assessing this client?
- A. Anemia
- B. Hypotension
- C. Weight loss
- D. Fever
Correct Answer: A
Rationale: Anemia is a common symptom of renal failure due to decreased erythropoietin production by the kidneys.
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 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.