EAQ 6

Before a transurethral resection of the prostate (TURP), a client asks about what to expect postoperatively. Which response by the nurse is most appropriate?

"There will be an indwelling urinary catheter and a continuous bladder irrigation in place."

A client is admitted with a diagnosis of acute pancreatitis. The medical and nursing measures for this client are aimed toward maintaining nutrition, promoting rest, maintaining fluid and electrolytes, and decreasing anxiety. Which interventions should the nurse implement? Select all that apply.

Administer analgesics Teach relaxation exercises Monitor cardiac rate and rhythm

A nurse is taking care of a client with cirrhosis of the liver. Which clinical manifestations should the nurse assess in the client? Select all that apply.

Ascites Pruritus Jaundice

The nurse reviews a medical record and is concerned that the client may develop hyperkalemia. Which disease increases the risk of hyperkalemia?

End-stage renal disease

When preparing a client for a liver biopsy, what should the nurse instruct the client to do?

Hold the breath at the moment of the actual biopsy

A client with limited mobility is being discharged. To prevent urinary stasis and formation of renal calculi, what should the nurse instruct the client to do?

Increase oral fluid intake to 2 to 3 L/day.

A nurse is caring for a client with hepatic encephalopathy and ascites. Which elements are important to include in this client's diet? Select all that apply.

Low sodium High vitamins Moderate protein

Which drug prescribed to a client with a urinary tract infection (UTI) turns urine reddish-orange in color?

Phenazopyridine

A client with end-stage kidney disease is receiving continuous ambulatory peritoneal dialysis. The nurse should monitor the client for which peritoneal dialysis complications? Select all that apply.

Tachycardia Cloudy outflow Abdominal pain

The nurse provides discharge instructions to a male client who had an ureterolithotomy. The client has a history of recurrent urinary tract infections (UTIs). For which indicators of a UTI should the nurse instruct the client?

Urgency or frequency of urination

A nurse is performing peritoneal dialysis for a client. Which action should the nurse take?

Warm the dialysate solution slightly before instillation.

A client is to have hemodialysis. What must the nurse do before this treatment?

Weigh the client to establish a baseline for later comparison.

A client is admitted to the hospital with suspected liver disease, and a needle biopsy of the liver is performed. After the procedure, the nurse should maintain the client in what position?

Right side-lying

A client is a candidate for intubation as a result of bleeding esophageal varices. Which type of tube should the nurse anticipate will most likely be used to meet the needs of this client?

Sengstaken-Blakemore

A nurse is caring for a client with end-stage renal disease who has a mature arteriovenous (AV) fistula. Which nursing care should be included in the client's plan of care? Select all that apply.

Auscultate for a bruit. Palpate the site to identify a thrill. Avoid drawing blood from the affected extremity.

A client who is receiving peritoneal dialysis reports severe respiratory difficulty. What immediate action should the nurse implement?

Auscultate the lungs.

A nurse is providing discharge instructions to a client diagnosed with cirrhosis and varices. Which information should the nurse include in the teaching session? Select all that apply.

Avoiding aspirin and aspirin-containing products Avoiding acetaminophen and products containing acetaminophen Avoiding coughing, sneezing, and straining to have a bowel movement

A client complains of nocturia, bladder pain, urinary frequency, urgency, and dribbling at the end of urination. On physical examination, the nurse finds a smooth, firm, and enlarged prostate. The digital rectal examination report indicates enlargement of prostate tissue surrounding the urethra. Which condition does the nurse suspect in the client?

Benign prostatic hyperplasia (BPH)

A client is admitted with renal calculi. Which clinical manifestations does a nurse expect the client to report? Select all that apply.

Blood in the urine Frequency and urgency of urination

If a client on peritoneal dialysis develops symptoms of severe respiratory difficulty during the infusion of the dialysate solution, what should the nurse do?

Drain the fluid from the peritoneal cavity.

The nurse is creating a discharge teaching plan for a client who had a subtotal gastrectomy. The nurse should include what instructions about minimizing dumping syndrome? Select all that apply.

Eat small, frequent meals. Lie down for one hour after eating.

A client is admitted to the hospital with a diagnosis of Crohn disease. What is most important for the nurse to include in the teaching plan for this client?

Meeting nutritional needs

The nursing instructor determines that the student nurse understands the type(s) of hepatitis that most commonly are spread by consuming contaminated food and water or by fecal contamination if the student identifies which of these diseases? Select all that apply.

Hep A Hep E

A nurse is assessing two clients. One client has ulcerative colitis, and the other client has Crohn disease. Which is more likely to be identified in the client with ulcerative colitis than in the client with Crohn disease?

Involvement starting distally with rectal bleeding that spreads continuously up the colon

The nurse is providing care to a client with ascites secondary to liver failure. What is appropriate to include in this client's care? Select all that apply.

Low sodium diet Daily abdominal girth measurements Daily weights

A client with Crohn disease is admitted to the hospital with a history of chronic, bloody diarrhea, weight loss, and signs of general malnutrition. The client has anemia, a low serum albumin level, and signs of negative nitrogen balance. The nurse concludes that the client's health status is related to what major deficiency?

Protein

A nurse is caring for a client with a diagnosis of chronic kidney failure who has just been told by the primary healthcare provider that hemodialysis is necessary. Which clinical manifestation indicates the need for hemodialysis?

Hyperkalemia

A client with a history of alcoholism and cirrhosis is admitted with severe dyspnea as a result of ascites. Which process that most likely caused the ascites should the nurse consider when planning care?

Increased pressure in the portal vein

A client is admitted to the hospital with a diagnosis of cirrhosis of the liver. For which assessment signs of hepatic encephalopathy should the nurse assess this client? Select all that apply.

Mental confusion Flapping hand tremors Musty, sweet breath odor

A client is diagnosed with calcium oxalate renal calculi. Which foods should the nurse teach the client to avoid? Select all that apply.

Tea Spinach Rhubarb