Management Quiz #5

"This must be reported to the Public Health Department and your sexual partners."

The client scheduled for a D&C is upset because the HCP told her she has syphilis. The client asks the nurse, "This is so embarrassing. Do you have to tell anyone about this?" Which statement is the nurse's best response?

300 mL

The client with chronic kidney disease is placed on a fluid restriction of 1,500 milliliters per day. On the 7 a.m. to 7 p.m. shift the client drank an 8-ounce cup of coffee, 8 ounces of juice, 16 ounces of tea, and 8 ounces of water with medications. What amount of fluid can the 7 p.m. to 7 a..m. nurse give to the client?

Notify the client's surgeon immediately.

The client with open surgery of the kidney has an AP 118 and B/P 88/58. Which intervention should the nurse implement first?

Weigh the client daily, first thing in the morning. Change the client's IV tubing with every TPN bag administered. Monitor the client's intake and output every shift.

The client is NPO and is receiving total parenteral nutrition (TPN) via a subclavian line. Which precautions should the nurse implement?

Escort the mother to a private area and talk to her.

The 18-year-old client diagnosed with renal trauma is admitted to the critical care unit after a serious motor vehicle accident resulting from driving under the influence. The mother comes to the unit and starts yelling at her son about "driving drunk." Which action should the nurse implement?

"It is recommended you get a flu vaccine yearly."

The 78-year-old client with Alport syndrome asks the clinic nurse, "What should I do so I won't get sick this winter?" Which priority statement is the nurse's best response?

1. Put a bedside commode at the client's bedside. 2. Instruct the client in providing a clean-catch specimen. 3. Give the client perineal pads to place insider her underwear. 4. Place an absorbent pad on the client's bed. 5. Have the unlicensed assistive personnel (UAP) make "potty" rounds on the client every 2 hours.

The 88-year-old female client is complaining of urinary frequency and dribbling. Which nursing interventions should be implemented? Rank in order of performance.

Obtain informed consent from the client's significant other.

The HCP orders an intravenous pyelogram for the 27-year-old male client diagnosed with R/O renal calculi. The client is diagnosed with schizophrenia and is delusional. Which action should the clinic nurse implement?

Bolus the client 300 mL of 0.9% saline solution.

The client receiving dialysis is complaining of being dizzy and light-headed. Which priority intervention should the nurse implement?

Do not take any action and allow the UAP to listen to the student.

The UAP in the school nurse's office is listening to a female student who is pregnant and scared to tell her parents. Which action should the school nurse implement?

Schedule a meeting with the staff to discuss the situation.

The charge nurse in a large outpatient clinic notices the staff members are arguing and irritable with one another and the atmosphere has been very tense for the past week. Which action should the charge nurse take?

The 24-year-old client who had a circumcision and is being prepared for discharge.

The charge nurse is making assignments in the day surgery center. Which client should be assigned to the most experienced nurse?

The client with a cystectomy who had a creation of an ileal conduit.

The charge nurse is making client assignments. Which client should the nurse assign to the graduate nurse who has just finished orientation?

Assign the LPN to change the client's ileal conduit bag.

The charge nurse is making shift assignments to the surgical staff, which consists of two nurses, two licensed practical nurses (LPNs), and two unlicensed assistive personnel (UAP). Which assignment would be most appropriate for the charge nurse to make?

Assess the staffing to determine which staff could be sent to ED.

The charge nurse on the renal unit is notified of a bus accident with multiple injuries and clients are being brought to the emergency department (ED). The hospital is implementing the disaster policy. Which action should the nurse take first?

Request the client give a midstream urine specimen.

The client comes to the clinic reporting pain and burning on urination. Which action should the nurse implement first?

The UAP takes the BP on the client's left arm.

The client diagnosed with chronic kidney disease (CKD), and who has a left forearm graft, is assigned to the nurse and unlicensed assistive personnel (UAP). Which action by the UAP requires immediate intervention by the nurse?

Instruct the UAP to strain the client's urine and place any sediment in a sterile container.

The client diagnosed with renal calculi is 1 hour post-procedure lithotripsy. Which task is most appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP)?

Place client's urine in an appropriate specimen container for 24 hours. Post signs on the client's door alerting staff to save all of the client's urine output.

The client diagnosed with renal calculi is scheduled for a 24-hour urine specimen collection. Which interventions should the nurse implement? Select all that apply.

A urinalysis showing blood in the urine.

The client had surgery to remove a kidney stone. Which of the following laboratory assessment data warrants intervention by the nurse?

1. Discontinue the intravenous line. 2. Start a new IV in the right hand. 3. Place a warm washcloth over the site. 4. Document the situation in the client's chart. 5. Complete an incident record.

The client has received IV solutions for 3 days through a 20-gauge IV catheter placed in the left cephalic vein. On morning rounds the nurse notes the IV site is tender to palpation, it is edematous, and a red streak has formed. Which interventions should the nurse implement? Rank in priority order.

The UAP increased the client's irrigation fluid to clear clots from the tubing.

The client is 1 day postoperative transurethral resection of the prostate (TURP). Which action by the unlicensed assistive personnel (UAP) warrants intervention by the nurse?

Have the client remain upright for 30 minutes after administering the medication.

The elderly female client diagnosed with osteoporosis is prescribed the biphosphonate medication alendronate (Fosamax). Which intervention is priority when administering this medication?

Recommend the client use a vaginal lubricant prior to intercourse.

The elderly female client tells the nurse, "I have vaginal dryness and it hurts when my husband and I make love." Which priority intervention should the nurse discuss with the client?

88 mL/hour

The elderly patient diagnosed with heart failure is scheduled to receive a unit of packed red blood cells (PRBCs). The PRBCs are prepared in 350 mL of solution. At what rate should the nurse set the pump?

Maintain the chain of custody for the specimen.

The employee health nurse is obtaining a urine specimen for a pre-employment drug screen. Which action should the nurse implement first?

"I have not had my period for 3 months."

The female client with renal calculi is scheduled for a STAT kidney, ureter, bladder (KUB). Which statement by the client warrants intervention by the nurse?

"The physical therapist will work with the client on strengthening and endurance."

The home health (HH) aide caring for the client who is postoperative kidney transplant asks the home health nurse, "Why is the physical therapist coming to visit the client?" Which statement is the home health nurse's best response?

"Saw palmetto is used to treat benign prostatic hypertrophy. Let him take it."

The home health (HH) aide tells the home health nurse one of the older male clients is taking an herbal supplement, saw palmetto, every day. Which statement is the nurse's best response?

Contact the agency chaplain to come talk to the client.

The home health (HH) nurse is admitting a female client diagnosed with end-stage renal disease who refuses to be placed on hemodialysis. The client is ready to die, but verbalizes having so many regrets in her life. Which intervention would be most appropriate for the nurse?

Check on the family 1 to 2 months after the death of the client.

The hospice nurse is providing follow-up care with the family member of a client who died with chronic renal disease. Which intervention is priority?

Assess the client's pain.

The male client diagnosed with renal calculi is admitted to the medical unit. Which intervention should the nurse implement first?

The client has a blood pressure reading of 184/102.

The male client with chronic kidney disease has received the initial dose of erythropoietin, a biological response modifier, 1 week ago. Which data warrants the nurse to notify the healthcare provider?

Instruct the client on appropriate fluid restrictions.

The nurse and unlicensed assistive personnel (UAP) are caring for a group of clients. Which nursing intervention should the nurse perform?

The UAP assists a client who received an IV narcotic analgesic 30 minutes ago to ambulate in the hall.

The nurse and unlicensed assistive personnel (UAP) are caring for clients on a surgical unit. Which action by the UAP warrants immediate intervention?

Take the vital signs of a client scheduled for a physical examination.

The nurse and unlicensed assistive personnel (UAP) are working in a family practice clinic. Which task should the nurse delegate to the UAP?

890 mL

The nurse emptied 2,340 mL from the drainage bag of a continuous irrigation of a client who had a transurethral resection of the prostate (TURP). The amount of irrigation in the hanging bag was 3,000 mL at the beginning of the shift. There was 1,550 mL left in the bag 8 hours later. What is the correct urine output at the end of the 8 hours?

The client on peritoneal dialysis who is complaining of a hard, rigid abdomen.

The nurse in the dialysis center is initiating the morning dialysis run. Which client should the nurse assess first?

The narcotic analgesic morphine IV infusion to the client who is 8 hours postoperative and is complaining of pain, rating it as a 7 on a 1 to 10 pain scale.

The nurse is administering medications to clients on a surgical unit. Which medication should the nurse administer first?

Ask a second nurse to attempt to start the IV.

The nurse is attempting to start an intravenous (IV) line in an elderly client who is dehydrated. After two unsuccessful attempts, which intervention should the nurse implement?

Assess the client's three-way urinary catheter for patency.

The nurse is caring for an 84-year-old male client diagnosed with benign prostatic hypertrophy. The client has undergone a transurethral resection of the prostate (TURP) and is complaining of bladder spasms. Which intervention should the nurse implement first?

The client has had a change in her mental status.

The nurse is caring for an elderly female client who has an indwelling catheter. Which data warrants notifying the healthcare provider?

The female client who is having burning and pain on urination.

The nurse is caring for clients in a family practice clinic. Which client should the nurse assess first?

The client diagnosed with nephrolithiasis who has hematuria and is complaining of pain, rating it as a 9 on a 1 to 10 pain scale.

The nurse is caring for clients on a renal unit and making assignments for the day shift. Which client should the nurse assess first?

The client with acute pyelonephritis who has nausea/vomiting and is dehydrated.

The nurse is caring for clients on a surgical unit. Which client should the nurse assess first after shift report?

Instruct the UAP to calculate the client's urinary intake and output.

The nurse is caring for clients on the renal unit. Which task is most appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP)?

The client with benign prostatic hypertrophy who has blood oozing from the intravenous site.

The nurse is caring for the following clients on a medical unit. Which client should the nurse assess first?

Consult with the pharmacist to determine any potential drug interactions.

The nurse is completing the admission assessment on the client scheduled for cystectomy with creation of an ileal conduit. The client tells the nurse, "I am taking saw palmetto for my enlarged prostate." Which intervention should the nurse implement first?

Excess fluid volume.

The nurse is developing a nursing care plan for the client diagnosed with chronic kidney disease. Which nursing problem should be addressed first?

Determine if the client has any betadine allergies.

The nurse is inserting an indwelling catheter into a male elderly client. Which intervention should the nurse implement first?

The UAP does not secure the tubing to the client's leg with tape.

The nurse is observing the unlicensed assistive personnel (UAP) provide care to a client with an indwelling catheter. Which action by the UAP warrants immediate intervention by the nurse?

Determine if the client's intravenous site is patent.

The nurse is preparing to administer intravenous narcotic medication to the client who has renal calculi and is complaining of pain rated as 8 on 1 to 10 pain scale. The client's vital signs are stable. Which intervention should the nurse implement first?

Acetaminophen (Tylenol), an analgesic, due in 5 minutes.

The nurse is preparing to administer medications. Which medication should the nurse administer first?

Quietly leave the room and come back later for the dressing change.

The nurse is preparing to perform a dressing change on a female who has end-stage renal disease. The nurse notes the client's husband is silently holding the client's hand and praying. Which action should the nurse implement first?

Determine whether the client has his or her routine medications.

The nurse is working at the emergency health clinic in a disaster shelter. Which intervention is priority when initially assessing the client?

Ask the LPN to administer the flu vaccine to the client.

The nurse manager in the medical-surgical outpatient clinic is making assignments. Which task is most appropriate to delegate/assign to the UAP/LPN?

Tell the LPN the nurse needs to talk to her in the office area.

The nurse observes an LPN discussing an intravenous pyelogram, a diagnostic test, with a client in the waiting room of the outpatient clinic. Which action should the nurse implement?

The client with renal vein thrombosis who has a heparin drip infusion and a PTT of 92.

The nurse on a medical unit has just received the evening shift report. Which client should the nurse assess first?

The appropriateness of the nurse's written documentation in the charts.

The unit manager on the renal unit is evaluating the staff nurse. Which data should be included in the nurse's yearly evaluation?

Assess the client's urine specimen and complete a renal assessment.

The unlicensed assistive personnel (UAP) reports to the nurse the client's urine output has bright red blood. Which intervention should the nurse implement first?

The LPN has the trough drawn after hanging the amino glycoside.

Which action by the licensed practical nurse (LPN) requires intervention by the critical care charge nurse?

The UAP is discussing client's condition in the waiting room.

Which behavior warrants intervention by the clinical manger in the medical-surgical outpatient unit?

Palpate the bladder after an incontinent episode.

Which intervention should the nurse implement first for the client diagnosed with urinary incontinence?

Perform the Crede's maneuver on the client.

Which intervention should the nurse implement first when assisting a client with a flaccid bladder to urinate?

Take and record the client's vital signs and pulse oximeter reading. Empty the client's indwelling catheter bag at the end of the shift. Assist the client to ambulate in the hallway three to four times a day.

Which interventions should the nurse delegate to the unlicensed assistive personnel (UAP) when caring for the client who is 2 days postoperative open surgery of the kidney? Select all that apply.

Potential for hemorrhage.

Which nursing diagnosis is priority for the client who has undergone a transurethral resection of the prostate (TURP)?

Insert an indwelling urinary catheter before surgery.

Which nursing task should the nurse on the renal unit assign to the licensed practical nurse (LPN)?

Escort the client with acute polynephritis to the radiology department for a CT scan.

Which task is most appropriate for the nurse on the renal unit to delegate to the unlicensed assistive personnel (UAP)?

Tell the UAP to apply an ice pack to the client who slipped and has a sprained right ankle.

Which task should the employee health nurse delegate to the unlicensed assistive personnel (UAP)?