URINARY REPRODUCTIVE SYSTEM HESI EXIT
A nurse is caring for a client who is scheduled to have a paracentesis. Immediately before the procedure, the nurse asks the client to void because a full bladder:
Increases the danger of puncture during the procedure
A client who is receiving hydrochlorothiazide (Hydrodiuril) asks what this drug actually does. What information about the drug's therapeutic action should the nurse consider when formulating a response?
Increases the excretion of sodium.
A client's retention catheter and continuous bladder irrigation (CBI) are to be removed two days after prostate surgery, and the nurse discusses what to expect with the client. Which expectation verbalized by the client indicates that the teaching is understood?
Some burning on urination is expected."
A client with metastatic breast cancer is started on a multiple drug regimen that includes docetaxel (Taxotere). The nurse assesses the client for which nontherapeutic effects of docetaxel? Select all that apply.
Alopecia Febrile neutropenia Hypersensitivity reaction
The nurse should wear what personal protective equipment when providing central venous access device site care?
Mask and sterile gloves
The nurse is caring for two clients. The first client had a below-the-knee amputation as a result of an accident. The second client had a below-the-knee amputation because of chronic decreased arterial perfusion. The nurse anticipates that the postoperative courses of these two clients may differ because the:
Second client's incision will take longer to heal
A primary health care provider prescribes peritoneal dialysis for a client with end-stage kidney disease (ESKD). What does the nurse expect the health care provider to prescribe to prepare for the insertion of the peritoneal dialysis catheter?
Cleansing enema
A client is receiving patient-controlled analgesia (PCA) after surgery. The nurse determines that with this type of therapy the:
Client is able to self-administer pain-relieving drugs as necessary
A nurse is caring for a client who has a disturbed body image as a result of a burn injury. Which is an important nursing intervention for this client?
Conveying a positive attitude toward the client
The nurse is teaching first aid to a group of community members. A participant asks what first aid should be administered to a person who suffers extensive burns. An appropriate response by the nurse is to call 911 and:
Cover the burned areas with a bed sheet
A client had a suprapubic prostatectomy. Which type of tube can the nurse expect the client to have when he returns to his room from the postanesthesia care unit?
Cystostomy
The nurse is caring for a client with acute renal failure. The most serious complication for this client is:
Infection
When the exposure method of treatment is used for burns, the nurse explains to the client that:
Isolation precautions will be required while hospitalized
A client with an invasive carcinoma of the bladder is receiving radiation to the lower abdomen in an attempt to shrink the tumor before surgery. What should the nurse do considering the side effects of radiation?
Observe feces for the presence of blood.
To assess a client's response to ongoing serum albumin therapy for cirrhosis of the liver, the nurse should:
Obtain the client's weight at least once every day
A nurse is caring for an older bedridden male client who is incontinent of urine. What nursing intervention is the most satisfactory initial approach to managing urinary incontinence?
Offering the urinal regularly
A client is at high risk for developing ascites because of cirrhosis of the liver. How should the nurse assess for the presence of ascites?
Percuss the client's abdomen and listen for dull sounds.
A client is admitted to the hospital with a diagnosis of dehydration and hypokalemia. What is important for the nurse to consider when administering potassium chloride intravenously (IV) to this client?
Oliguria is an indication for withholding IV potassium
A nurse determines that a client in the acute phase of burns has eaten only a small portion of each meal. Considering this finding, the nurse should assess the client for:
Prolonged wound healing
A nurse understands that a temporary heterograft (pig skin) is used to treat burns because this graft:
Promotes rapid epithelialization
A client is scheduled for a computed tomography (CT) scan of the chest with intravenous (IV) contrast. What should the nurse assess before the test is performed?
Serum creatinine level
A client's burn wounds are scheduled to be debrided mechanically. The nurse explains that this procedure involves:
Surgical removal of the dead tissue; a health care provider will perform the procedure
The nurse is caring for a client that weighs 90 kilograms. The nurse is determining the client's response to fluid replacement therapy. The clinical finding that indicates adequate tissue perfusion to vital organs is:
Urinary output of 60 mL/hr
The nurse determines that which genitourinary factor contributes to urinary incontinence in older adults?
Urinary tract infection
If a client on peritoneal dialysis develops symptoms of severe respiratory difficulty during the infusion of the dialysate solution, the nurse should:
Drain the fluid from the peritoneal cavity
A nurse is caring for a client who had a kidney transplant. What sign indicates that the client may be rejecting the transplanted kidney?
Fever
A nurse assesses a newly admitted client with renal colic to determine the signs and symptoms that are present. The nurse assesses the client for which primary subjective symptom?
Flank discomfort
A client is admitted to the hospital with a diagnosis of cirrhosis of the liver with ascites. What should the nurse do when preparing this client for a paracentesis?
Instruct the client to empty the bladder
A client who had a continent urostomy created complains of postoperative pain. What should the nurse do first?
Interview the client to gather more information. A client reports urinary frequency and burning. To determine if there is tenderness that indicates the presence of an ascending urinary tract infection, the nurse should palpate which area? Costovertebral angle
When administering albumin intravenously to a client with cirrhosis, the nurse expects what fluid shift?
Intracellular compartment to extracellular compartment
A client with scleroderma complains of numbness and tingling in the hands followed by blanching of the fingers. The nurse concludes that the client has Raynaud's phenomenon, a condition commonly associated with scleroderma. The nurse plans to advise the client to:
Keep the hands warm by wearing gloves
The nurse providing postoperative care for a client who had kidney surgery reviews the client's urinalysis results. The nurse concludes that the presence of what substance in the urine needs to be reported to the health care provider?
Large proteins
A client scheduled for a transurethral prostatectomy expresses concern about the effect the surgery will have on sexual ability. The nurse explains that, after the surgery, the client:
May experience retrograde ejaculations
A client is admitted to the hospital after a motor vehicle accident with multiple abrasions and lacerations to the chest and all four extremities. The nurse helps the client select food items for the upcoming meals and recommends:
Meatloaf and strawberries
A male client comes to the emergency department because he has a discharge from his penis. The health care provider suspects gonorrhea and asks the nurse to obtain a specimen and to send it for a culture. What should the nurse do?
Obtain a specimen of the drainage from the distal urethra.
A nurse is caring for a client who had an insertion of radium for cancer of the cervix. What reaction by the client may indicate a toxic effect?
Pain
A nurse is caring for a client who just had surgery to repair an inguinal hernia. To limit a common complication associated with this surgery, the nurse should:
Place a support under the scrotum
A client is admitted to the hospital with deep partial-thickness burns to both hands and forearms after an accident. How should the nurse apply the prescribed antimicrobial medication?
Place the medication directly on the burn wound in a thin layer using sterile gloves.
A nurse is caring for a client with severe burns. The nurse determines that this type of client is at risk for hypovolemic shock because of the:
Plasma proteins moving out of the intravascular compartment
A client with pulmonary tuberculosis discusses the dietary plan with the nurse. The nurse expects that the type of diet that will be prescribed for the client is:
Small, frequent, high-calorie meals
A nurse is providing preoperative teaching for a client who is scheduled for a transurethral resection of the prostate. What should the nurse include in the client's postoperative teaching plan?
Spasms of the bladder occur during the first 24 to 48 hours
A nurse is teaching a postoperative client about the importance of vitamin C for wound healing. Which food selection demonstrates the client is applying the information correctly?
Strawberries
To help prevent a cycle of recurring urinary tract infections, the nurse should plan to instruct a female client to:
Urinate as soon as possible after intercourse
A client who sustained a burn injury involving 36% of the body surface area is receiving hydrotherapy. What is the best nursing intervention when providing wound care?
Use a consistent approach to care and encourage participation.
Before administering preoperative medication to a client, the nurse plans to:
Verify the consent
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 receiving furosemide (Lasix) to relieve edema. The nurse should monitor the client for which responses? Select all that apply.
Weight loss Excessive loss of potassium ions
After surgery for cancer, a client is to receive chemotherapy. When teaching the client about the side effects of chemotherapy, the nurse emphasizes that the occurrence of alopecia is:
Not permanent
A client is admitted to the hospital with severe renal colic caused by a ureteral calculus. Later that evening the client's urinary output is much less than the intake. When it is confirmed that the bladder is not distended, the nurse should suspect the development of:
Hydroureter
A client is admitted to the hospital with a diagnosis of chronic kidney failure. For signs of what electrolyte imbalance should the nurse monitor the client?
Hypocalcemia
The nurse is caring for a client that had a colostomy three days ago. The primary nursing intervention for this client is to:
Observe drainage and the condition of the abdominal incision
A client with burns develops a wound infection. The nurse plans to teach the client that local wound infections primarily are treated with what type of antibiotics?
Topical
A client with psoriasis asks the nurse what can help this condition. Which should the nurse include in a teaching plan for this client?
Topical application of steroids
An adult client is receiving lactated Ringers (LR) for burns to the genitalia. The nurse calculates which total body surface area (TBSA) for the burn?
1%
Acyclovir (Zovirax) 0.8 g by mouth is prescribed for a client with herpes zoster. The oral suspension contains 200 mg/5 mL. How much solution should the nurse administer? Record your answer using a whole number. ___mL
20
A client is admitted for treatment of partial- and full-thickness burns of the entire right lower extremity and the anterior portion of the right upper extremity. Performing an immediate appraisal, using the Rule of Nines, what is the percent of body surface area burned?
22.5%
A health care provider prescribes 2 L of intravenous (IV) fluid to be administered every 12 hours to a client who sustained a burn injury. The drop factor of the tubing is 10 gtts/mL. The nurse should set the flow rate at how many drops per minute? Record the answer using a whole number. ___ gtts/min
27.77777 = 28
A client who is receiving combination chemotherapy for stage II Hodgkin disease is at risk for stomatitis. The nurse's teaching plan should include instructions to:
Clean the mouth with a soft toothbrush or a gentle spray
A client has been in a coma for two months and is maintained on bed rest. At what angle should the nurse adjust the head of the bed to prevent the effects of shearing force?
30 degrees
A burn victim has waxy white areas interspersed with pink and red areas on the chest and all of both arms. The nurse calculates that the percentage of total body surface area (TBSA) on which the client has sustained burns is:
36
A client is hospitalized for intravenous antibiotic therapy and an incision and drainage of an abscess that developed at the site of a puncture wound. When should the nurse begin to teach the client about how to care for the wound?
In the preoperative period
A client is admitted to the hospital with partial- and full-thickness burns of the chest sustained in a house fire. What is the nurse's priority concern?
Inadequate gas exchange because of smoke inhalation
A female client has a history of frequent urinary tract infections (UTIs). To decrease the incidence of the infections, the nurse instructs the client to increase fluid intake and:
Empty the bladder every three hours
A health care provider prescribes bed rest for a client after surgery. What nursing intervention is most beneficial in preventing skin breakdown?
Encourage movement in bed
A client is diagnosed with psoriasis and the nurse is providing health teaching concerning skin care at home. What recommendation does the nurse include in the teaching?
Apply lotion several time
A client who had a lithotripsy for a renal calculus is to be discharged from the hospital. What should the nurse include in the home care instructions?
Drink at least 3 L of fluid daily for four weeks
How should a nurse prepare a client for cranial surgery?
Obtain the client's consent to shave the head
A nurse reviews the postoperative plan of care for a client who is scheduled for a ligation of hemorrhoids with latex bands. To decrease local discomfort after the procedure, the nurse expects a prescription for
Sitz baths
A nurse is assessing a newly admitted client with a pressure ulcer indicated in the picture. What stage pressure ulcer should the nurse
Stage II
A 40-year-old client scheduled for a hemicolectomy because of ulcerative colitis asks if having a hemicolectomy means wearing a pouch and having bowel movements in an abnormal way. Which is the best response by the nurse?
"No, only part of the colon is removed and the rest reattached."
A client is admitted to the hospital for the medical management of burns over 18% of the body's surface. What should the nurse teach the client to help manage pain during dressing changes?
Deep breathing exercises
A client was admitted with full-thickness burns two weeks ago. Since admission, the client has lost an average of a pound of weight each day. The nurse expects the client's diet to be adjusted to include:
High-protein drinks
A nurse is caring for a client with scabies. Which information about scabies should the nurse consider when planning care for this client?
Highly contagious
A client with a detached retina is scheduled for surgery to reattach the retina. What should the nurse address in the preoperative teaching plan about the procedure used with this surgery?
Laser technique
A client receives an autograft for a severe burn and is taught how to change the dressing. One week after receiving the graft, the client identifies that the edges of the graft are curling up and asks the nurse about it. What is the best response by the nurse?
May I take a look at it?
A health care provider prescribe 36 units of nph and 12 units of regular insulin. the nurse plan to administer these drugs in one syringe. identify the steps in this procedure by listing the numbers by each picture to the step below in priority order.( star with the number of the picture that represents the first steep and end with the number by the picture that represents the last steep)
1- Inject air equal to NPH dose into NPH vial 2- Insert regular insulin bottle and withdraw regular insulin dose 3- Inject air equal to regular dose into regular vial 4- Insert NPH vial and withdraw NPH dose A/ 3, 1, 2, 4
A client with a stage IV pressure ulcer is to receive 0.22 g of zinc sulfate by mouth. Each tablet contains 110 mg. How many tablets should the nurse administer? Record your answer using a whole number.
2
A nurse is assessing a client eight hours after the creation of a colostomy. Which assessment finding should the nurse expect?
Absence of drainage from the colostomy
A nurse is caring for a client with complications associated with peritoneal dialysis. For which signs and symptoms should the nurse monitor the client? Select all that apply.
1.Tachycardia 2. Cloudy outflow 3.Abdominal pain
How do you mix insulin? Clear before Cloudy (NPH)!!!
1. draw up air to equal total insulin 2. wipe vial runner with alcohol 3. inject the amount of air to equal the amount of cloudy insulin into the cloudy vial. BE CAREFUL NOT TO INJECT INTO THE SOLUTION 4. Inject the remaining air into clear vial and draw up the clear insulin 5. reinsert the needle into the cloudy vial and withdraw the desired amount
A nurse is assessing the urine of a client with a urinary tract infection. For which characteristic should the nurse assess each specimen of urine?
Clarity
A client has a fracture of the tibia and a cast is applied. When caring for the client, the nurse should:
Elevate the affected leg above the level of the heart
When caring for a client who has a burn in the emergent stage, which has the highest priority as part of an accurate burn assessment?
Extent of burn
During the first 48 hours after a thermal injury, the nurse should assess the client for:
Hyperkalemia and hyponatremia-
A client with tuberculosis is started on a chemotherapy protocol that includes rifampin (RIF). The nurse evaluates that the teaching about rifampin is effective when the client states:
I can expect my urine to turn orange from this medication."
Which statement regarding treatment with interferon indicates that the client understands the nurse's teaching?
I will drink two to three quarts of fluid a day."
The nurse is caring for a client who returns from surgery with a catheter that is attached to a portable wound drainage system exiting from the surgical site. The principle underlying the function of a portable drainage system is:
Negative pressure
A client who had a suprapubic prostatectomy returns from the postanesthesia care unit and accidentally pulls out the urethral catheter. What should the nurse do first?
Notify the health care provider.
A client is diagnosed with calcium oxalate renal calculi. Which foods should the nurse teach the client to avoid? Select all that apply.
Nuts Spina Rhubarb
A nurse is caring for a client who is admitted with ureteral colic and hematuria. The client also has stage 1 hypertension and is overweight. Which assessment finding should the nurse be most concerned about at this time?
Pain
The nurse is providing postoperative care to a client who had an abdominal cholecystectomy and choledochostomy who has a T-tube and a nasogastric tube in place. The client refuses deep breathing and coughing exercises. The nurse concludes that the most probable reason for the noncompliance is that during the exercises:
Pain at the incision site increases
A client is admitted to the hospital with a diagnosis of chronic kidney disease. Which responses should the nurse expect the client to exhibit? Select all that apply.
Paresthesia Hypertension
A nurse administers sodium polystyrene sulfonate (Kayexalate) to a client with chronic renal failure. Which finding provides evidence that the intervention is effective?
Potassium decreases to 4.2 mEq/L
A client with scleroderma is scheduled to begin a regimen of daily exercises. The nurse explains that the purpose of the exercises is to:
Preserve muscle strength
A nurse places a client with severe burns on a circulating air bed. What is the primary reason why the nurse implements this action?
Prevent pressure on peripheral blood vessels
What is the most basic method the nurse can use when encouraging hospitalized clients to void?
Providing privacy
A nurse is counseling a woman who had recurrent urinary tract infections. What factor should the nurse explain is the reason why women are at a greater risk than men for contracting a urinary tract infection?
Proximity of the urethra to the anus
A client rescued from a burning building has partial- and full-thickness burns over 40% of the body. Which is the initial physiologic change that the nurse can expect?
An increase in serum potassium
A client with acute kidney failure becomes confused and irritable. Which does the nurse determine is the most likely cause of this behavior?
An increased blood urea nitrogen level
A client with end-stage renal disease is hospitalized. For what signs and symptoms of complications should the nurse monitor the client? Select all that apply
Anemia Dyspnea Anasarca
A client is scheduled for surgery. Legally, the client may not sign the operative consent if:
Any sedative type of medication has been given recently
To prevent bleeding after a suprapubic prostatectomy, the client should be instructed to avoid straining on defecation. Which foods should the nurse encourage the client to eat to help prevent constipation during the recovery period? Select all that apply.
Apple Oatmeal Green peas
A client with myasthenia gravis improves and is discharged from the hospital. The discharge medications include pyridostigmine bromide (Mestinon) 10 mg every six hours. The nurse evaluates that the drug regimen is understood when the client says, "I should:
Set an alarm so I take the medication on time."
The nurse should ask the client with secondary syphilis about sexual contacts during the past:
Six months
A nurse is caring for a client with a diagnosis of necrotizing fasciitis. Which is the primary concern of the nurse when caring for this client?
Skin integrity
A client with end-stage kidney disease is receiving continuous ambulatory peritoneal dialysis. The nurse should monitor the client for which manifestations of complications? Select all that apply.
Tachycardia Cloudy outflow Abdominal pain
A client is scheduled for an intravenous pyelogram (IVP). The nurse explains that on the day before the IVP the client must:
Take a laxative before going to bed
A nurse is notified that the latest potassium level for a client in acute renal failure is 6.2 mEq. What action should the nurse take?
Take vital signs and notify the primary health care provider
A nurse is providing client teaching to a woman who has recurrent urinary tract infections. Which information should the nurse include concerning the reason why women are more susceptible to urinary tract infections than men?
The length of the urethra
A client is diagnosed as having cancer of the breast and is admitted to the hospital for a lumpectomy to be followed by radiation. While being admitted to ambulatory surgery by the nurse, the client has tears in her eyes and her chin is quivering. In a shaky voice the client says, "I can't believe this is happening." The nurse's best response is:
This must be a very scary time for you."
. A client is scheduled for radiation treatments Monday through Friday. The client asks why the treatments will not be given on Saturday and Sunday. The nurse's best response is:
This type of schedule gives noncancerous cells time to recover."
A nurse is caring for a client who is admitted to the hospital for medical management of heart failure and severe peripheral edema. For which clinical indicators associated with unresolved severe peripheral edema should the nurse assess the client?
Tissue ischemi
What should the nurse teach a client about how to care for the skin around a colostomy stoma?
Wash with soap and water.
A client with the diagnosis of chronic kidney disease develops hypocalcemia. Which clinical manifestations should the nurse expect the client with hypocalcemia to exhibit? Select all that apply.
Chvostek sign Muscle cramps
A man with benign prostatic hyperplasia is scheduled for a transurethral incision of the prostate (TUIP). As he is being admitted to the surgical unit, he tells the nurse he is concerned that his operation will result in impotence. What is the best response by the nurse?
"I can understand your concern, but this operation usually does not cause impotence."
A client with cancer of the bladder is admitted to the hospital for diagnostic tests to determine the extent of the disease. While the nurse is caring for the client, the client asks, "If they remove my bladder, how will I be able to urinate?" Which is the best response by the nurse?
"I know you're upset, but there are alternatives to removing your bladder."
A carpenter with full-thickness burns of the entire right arm confides, "I'll never be able to use my arm again and I'll be scarred forever." The nurse's best initial response is:
"I know you're worried, but it is too early to tell how much scarring will occur."
A nurse is teaching a community class about campfire safety. A class participant asks about what to do if a person catches on fire. How should the nurse respond?
"Roll the person in the grass."
A client with chronic kidney disease is admitted to the hospital with severe infection and anemia. The client is depressed and irritable. The client's spouse asks the nurse about the anticipated plan of care. What is an appropriate nursing response?
"The intake of meat, eggs, and cheese will be restricted so the kidneys can clear the body of waste products."
A client newly diagnosed with scleroderma states, "Where did I get this from?" The nurse's best response is, "Although no cause has been determined for scleroderma, it is thought to be the result of:
. autoimmunity."
Which nursing action is most important to promote the nutritional status of a client during the acute phase of treatment following extensive burns?
Administer the prescribed intravenous fluid with the added vitamin C.
A client with advanced cancer of the bladder is scheduled for a cystectomy and ileal conduit. What intervention does the nurse anticipate the health care provider will prescribe to prepare the client for surgery?
Administration of neomycin sulfate
A client has a diagnosis of partial-thickness burns. The nurse recalls that the client's burn is different than full-thickness burns in that partial-thickness burns:
Are often painful, reddened, and have blisters
The nurse is planning the care for a client with a body surface burn injury of 55%. The nurse understands that clients with burn injuries:
Are prone to poor healing because of a hypermetabolic state
Which information should the nurse include in a teaching plan for a client whose burns are being treated with the exposure method?
Aseptic techniques are required.
After a transurethral vaporization of the prostate, the client returns to the unit with an indwelling urinary catheter and a continuous bladder irrigation. The client puts the call light on to report the need to urinate. What should the nurse do first?
Assess that the tubing attached to the collection bag is patent A nurse is caring for a client with a diagnosis of renal calculi secondary to hyperparathyroidism. Which type of diet should the nurse explore with the client when providing discharge information? Low calcium
A client arrives at the emergency department after being bitten by a dog. The bite involved tearing of skin and deep soft tissue injury. The first nursing action is to:
Assess the client's injury, vital signs, and past history
A client has a basal cell epithelioma that is scheduled to be removed. The client expresses concerns that the cancer has spread. What is the best response by the nurse?
Basal cell tumors usually do not spread."
A client who was hospitalized with partial- and full-thickness burns over 30% of the total body surface area is to be discharged. The client asks the nurse, "How will my spouse be able to care for me at home?" How should the nurse interpret this statement?
Beginning realization of implications for the future
The nurse is assessing a client 12 hours after the client sustained a deep partial-thickness burn on the forearm. What characteristics should the nurse expect to identify when assessing the injured tissue?
Blistered and wet
Which clinical manifestations does a nurse expect that a client with renal calculi might report? Select all that apply.
Blood in the urine Frequency and urgency of urination
A client with systemic lupus erythematosus is taking prednisone. The nurse anticipates that the steroid may cause hypokalemia. Taking into consideration food preferences, the nurse encourages the client to eat:
Broccoli
A client with a urinary retention catheter reports discomfort in the bladder and urethra. What should the nurse do first?
Check the patency of the catheter.
The client is scheduled for an abdominal hysterectomy with a bilateral oophorectomy. As the nurse prepares to have her sign the informed consent, she asks how long she should wait to become pregnant. What would be the best response?
Call the surgeon immediately and hold preoperative medications.
A male client with ascites is to have a paracentesis and has signed the consent. While the nurse is caring for him, he says that he has changed his mind and no longer wants the procedure. The best initial response by the nurse is:
Can you tell me why you decided to refuse the procedure?
A client receiving combination chemotherapy for treatment of metastatic carcinoma asks the nurse in the clinic why more than one type of drug is necessary. Which concept is most important to teach the client in relation to why drug cocktails are more effective than a single drug in cancer therapy?
Cellular growth cycle
Two days after a severely burned client is admitted to the hospital, the client begins to exhibit restlessness. The nurse determines that this most likely indicates that the client is developing:
Cerebral hypoxia.
A nurse is assessing the urine of a client with a urinary tract infection. What appearance should the nurse expect this client's urine to have?
Cloudy
Sterile warm saline soaks three times a day are prescribed for a client with cellulitis from a puncture wound. The primary nurse places a clean basin, washcloth, and protective pad at the bedside in preparation for the soak but is unable to continue the procedure. What should the nurse assigned to complete the soak do?
Collect the new supplies before starting.
A person on the beach sustains a deep partial-thickness burn because of a severe sunburn. What is the best first-aid measure that a nurse should instruct the person to apply before seeking health care?
Cool, moist towels
A client is admitted to the hospital with urinary retention, and an indwelling urinary catheter is prescribed by the health care provider. What should the nurse do to help prevent the client from developing a urinary tract infection?
Maintain the prescribed hydration
A client with ascites is scheduled to have a paracentesis. What should the nurse include in the plan of care?
Instruct the client to urinate before the procedure
A client with a full-thickness burn receives an allograft. Several days later the client points out that the graft is coming off at the edges. What is the nurse's best response?
It is a temporary graft; it is expected to fall off."
A client is admitted to the burn unit with partial-thickness burns over 30% of the body surface area. Twenty-four hours later, the client, who has an IV of 5% dextrose in saline running, has tremors, twitching, and signs of disorientation. During the past hour the urinary output was 110 mL. What should the nurse do next?
Slow the IV rate and notify the health care provider
A nurse is assessing a client during the first 24 hours after a burn injury. Which sign indicates to the nurse that fluid replacement therapy is adequate?
Slowing of a previously rapid pulse
What should the nurse do to obtain an accurate urine output for a client with a continuous bladder irrigation (CBI)?
Subtract the volume of irrigant from the total drainage.
A nurse is caring for a client with an indwelling urinary catheter. What is the most important action for the nurse to implement when irrigating the bladder?
Use sterile equipment.
A home health nurse teaches a family member to cleanse a client's wound and apply a sterile dressing. Which action by the family member during a return demonstration indicates the need for additional teaching?
Using a back-and-forth motion while cleaning the wound
A client with end-stage renal disease is accepted for a kidney transplant and attends a group educational program for potential transplant candidates. The client asks the nurse which kidney will be removed. What is the nurse's best response?
"Neither of your kidneys will be removed unless it is infected
A client is rescued from a house fire and arrives at the emergency department one hour after the rescue. The client weighs 132 pounds and is burned over 35% of the body. The nurse expects that the amount of lactated Ringers solution that will be prescribed to be infused in the next eight hours is:
4200 m
The nurse uses the rule of nines to estimate the percentage of the burn surface area on a client who has burns covering the entire surface of both arms, the posterior trunk, the genitals, and the left leg. The nurse estimates the surface area to be?
55
The nurse is providing care to a client who is being treated for bacterial cystitis. Before discharge, it is most important for the client to:
Achieve relief of symptoms and to maintain kidney function
A client's extensive burns are being treated with silver nitrate 0.5% dressings. A week after treatment is begun, the nurse identifies that the client's sodium level is 135 mEq/L and the potassium level is 3.0 mEq/L. The nurse notifies the primary health care provider and expects a prescription to:
Add potassium chloride (KCl) to the existing lactated Ringers intravenous (IV) solution
An ambulatory client with benign prostatic hyperplasia tells the nurse on morning rounds that he has not been able to void. The nurse assesses the client and determines that his bladder is distended. What should the nurse do?
Assist him into a warm shower.
To facilitate micturition in a male client, the nurse should instruct him to:
Assume the standing position for voiding
A client who is pregnant and expecting a boy asks the nurse when mature sperm cells form. The nurse bases her response on the knowledge that spermatogenesis occurs:
At the time of puberty
A nurse is caring for a client with end-stage renal disease who has a mature arteriovenous (AV) fistula. What 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 health care provider prescribes tolterodine (Detrol) for a client with an overactive bladder. What is most important for the nurse to teach the client to do?
Avoid activities requiring alertness until the response to medication is known.
The nurse reviews the medical records of four male clients and concludes that the client that is at highest risk of developing prostate cancer is the:
Black 55-year-old
A client has been receiving hemodialysis for several months. The nurse considers that bleeding into the gastrointestinal (GI) tract is of particular significance to a client with chronic kidney disease because:
Blood is digested, thereby increasing the kidneys' protein load
Which nursing action can best prevent infection from a urinary retention catheter?
Cleansing around the meatus routinely A 75-year-old male with a history of cancer of the prostate is admitted for a prostatectomy. The client's prostate specific antigen (PSA) levels have been increasing. This finding should prompt the nurse to include what in the client's plan of care? Handle the client gently when turning
The nurse is providing care for a client diagnosed with invasive cancer of the head of the pancreas that has had a permanent biliary drainage tube (T-tube) inserted to provide palliative care. Postoperatively, the nurse should care for the T-tube by:
Cleansing the area around the insertion site to prevent skin breakdown
A health care provider prescribes the application of a warm soak to an intravenous (IV) site that has infiltrated. What principle does the nurse determine is in operation when the application of local heat transfers temperature to the body?
Conduction
A nurse is caring for a client with chronic kidney failure. Which clinical findings should the nurse expect when assessing this client? Select all that apply.
Lethargy Muscle twitching
A client is receiving combination chemotherapy for treatment of metastatic carcinoma. For which systemic side effect should the nurse monitor the client?
Leukopenia
The nurse is teaching campfire safety to a group of community members and includes information about what to do if a person catches on fire. The nurse teaches that the most effective method for putting out the flames is to:
Log-roll the victim in the grass
At 10 AM the nurse hangs a 1000 mL bag of D5W with 20 mEq of potassium chloride to be administered at 80 mL/hr. At noon the health care provider prescribes a stat infusion of an intravenous (IV) antibiotic of 100 mL to be administered via piggyback over one hour. How much later than expected will it take the primary bag to empty if the nurse interrupts the primary infusion to use the circulatory access for the secondary infusion of the antibiotic?
One hour
A nurse is monitoring a client with renal failure for signs of fluid excess. Which finding does the nurse identify as inconsistent with fluid excess?
Orthostatic hypotension
A nurse is caring for a client who is experiencing urinary incontinence. The client has an involuntary loss of small amounts (25 to 35 mL) of urine from an overdistended bladder. This should be documented in the medical record as:
Overflow incontinence
. A nurse is about to perform a wound irrigation on a client who had a left hemispheric stroke one year ago. What assessment is most important for the nurse to perform before beginning the irrigation?
Pain
A client who has been receiving hemodialysis for several years is to receive a kidney transplant. What should the nurse say in the client's preoperative teaching plan? Select all that apply.
Precautions are needed to prevent infection The kidney may not function immediately A urinary catheter will be present postoperatively
The nurse is caring for a client in the postanesthesia care unit. The client had a suprapubic prostatectomy for cancer of the prostate and has a continuous bladder irrigation in place. The purpose of this irrigation is to:
Prevent the development of clots in the bladder
A nurse is caring for a client with a diagnosis of cancer of the prostate. The nurse should teach the client that which serum level will be monitored throughout the course of the disease?
Prostate-specific antigen (PSA)
A nurse is teaching the importance of annual physical examinations to an adult health and wellness class. The nurse reinforces that it is important for men who are middle-aged and older to have what laboratory test annually?
Prostate-specific antigen (PSA)
A psychological problem that frequently occurs when a client is on hemodialysis is:
Reactive depression
The nurse is caring for a client four days after the client had a cystectomy and formation of a continent diversion. After observing mucous threads in the client's urine, the nurse should:
Recognize that this is an expected response
A client has a heminephrectomy and returns from the postanesthesia care unit with a nephrostomy tube and an indwelling urinary catheter. The client's urinary output is 50 mL/hr. What is the nurse's next action?
Record the findings.
An adolescent girl who has sustained deep partial-thickness burns of the face because of excessive exposure to the sun exclaims, "Prom night is only four weeks away. I'll never be healed!" What is the nurse's best response?
Recovery will take approximately three weeks
A state's Nurse Practice Act does not allow a registered nurse (RN) to suture wounds. The primary health care provider offers to teach the RN how to suture and tells the RN that minor wounds may be sutured without supervision. The nurse should:
Refuse to suture wounds
A client who is dying decides to consent to eye donation for organ transplantation. Statutes that address organ transplantation attempt to prevent abuse by:
Requiring participating institutions to have review boards
A nurse is caring for a client who has a radium implant for cancer of the cervix. What is the priority nursing intervention?
Restrict visitors to a 10-minute stay.
The nurse is providing dietary teaching to a 40-year-old client who is receiving hemodialysis. The nurse should encourage the client to include what in the client's dietary plan?
Rice
A person sustains severe burns of the arms and is waiting for emergency services to arrive. A nurse bystander responds to the scene. Another bystander is getting ready to apply butter to the burns, stating that it will provide soothing relief. An appropriate response by the nurse is, "I wouldn't advise putting the butter on. Our focus should be on:
covering up the victim with one of those tablecloths."
The nurse provides teaching to a client diagnosed with pulmonary tuberculosis that will begin taking pyrazinamide (PZA). The nurse concludes that the teaching is effective when the client says, "I will:
drink at least 2 quarts of fluid a day."
A client who just had a kidney transplant is transferred from the postanesthesia care unit (PACU) to the intensive care unit (ICU). The nurse in the ICU should monitor the client's urinary output every:
hour
The health care provider prescribes finasteride (Proscar) for a client with benign prostatic hyperplasia. The nurse informs the client that:
protection should be worn during intercourse with a pregnant female
After surgery to create an ileal conduit, a client is admitted to the postanesthesia care unit. Which clinical finding during the first hour of the postoperative period should the nurse report to the health care provider?
Absence of urinary output
A client with lymphosarcoma is receiving allopurinol (Zyloprim) and methotrexate (Rheumatrex). The nurse can help the client prevent complications related to uric acid nephropathy by administering the:
Allopurinol and encouraging the intake of fluid
A hospitalized client develops an infection at a catheter insertion site. The nurse uses the term iatrogenic when describing this infection because it resulted from:
A procedure performed at the hospital
A client who is to receive radiation for cancer says to the nurse, "My family and friends say that I will get a radiation burn." The best response by the nurse is:
"A localized skin reaction usually occurs."
A client is scheduled for a transurethral resection of the prostate. What should the nurse tell the client to expect after surgery?
"An indwelling urinary catheter is required for at least a day."
A client who is to receive external radiation therapy says to the nurse, "My family said that I will get a radiation burn." What is the nurse's best response?
"A localized skin reaction usually occurs.
During a first aid class, a student asks what should be done if a person's clothes catch on fire. The nurse explains that after the flames are extinguished it is most important to:
Assess the person's breathing
The nurse recalls that what scientific principle is basic to caring for a client with an indwelling urinary catheter?
Gravity
The nurse provides discharge instructions to a male client who had a ureterolithotomy. The client has a history of recurrent urinary tract infections (UTIs). The teaching should include that indicators of a UTI are:
Urgency or frequency of urination
The nurse is providing education to a client with calculi in the calyces of the right kidney. The client is scheduled to have the calculi removed. What should the nurse include in the teaching?
After surgery, there will be a small incision in the right flank area
A client with chronic kidney disease has been on hemodialysis for two years. The client relates to a nurse in the dialysis unit in an angry, critical manner and frequently does not follow the prescribed diet or take prescribed medications. What does the nurse identify as the most likely underlying cause of this behavior?
A defense against underlying depression and fear
A client is receiving total parenteral nutrition via a central venous access catheter. When providing care to the site, the nurse should wear:
A mask and sterile gloves
The nurse is preparing to administer a prescribed intravenous solution that contains potassium chloride to a client. The nurse determines that the administration should be held and the primary health care provider contacted when the client is assessed to have:
A urinary output of 200 mL during the previous 8-hour shift
A client has acute tubulointerstitial renal disease and is experiencing fluid and electrolyte imbalances. The client is confused and complains of nausea and muscle weakness. What should the nurse anticipate will be prescribed to help correct the electrolyte imbalance associated with this diagnosis?
Administer a cation exchange resin
A client is diagnosed with bladder cancer, and a cystectomy and an ileal conduit are scheduled. What should the nurse plan to do preoperatively?
Administer cleansing enemas and laxatives as prescribed.
The nurse is caring for a client who has been bitten by a raccoon. The client states, "Where I live, there seems to be raccoons and wild animals everywhere." The nurse recalls that rabies can be described as:
An acute viral infection, characterized by convulsions and difficulty swallowing, that affects the nervous system
A nurse is caring for a client who is receiving radiation therapy. What information about skin care should the nurse include in the teaching plan?
Avoid the application of lotions and powders over the area
The nurse is caring for a client with burns and reviews the client's laboratory results: blood urea nitrogen (BUN) 30 mg/dL, creatinine 2.4 mg/dL, serum potassium 6.3 mEq/L, pH 7.1, Po2 90 mm Hg, and Hgb 7.4 g/dL. The nurse concludes that these findings indicate:
Azotemia
A nurse is caring for a client with end-stage renal disease. Which clinical indicators of end-stage renal disease should the nurse expect? Select all that apply.
Azotemia Hypertension
After a prostatectomy, the client's retention catheter is pulled taut and is taped to the thigh. The client reports that the catheter is pulled too tight. What is the best initial action for the nurse to take?
Explain that the traction helps to control bleeding.
A nurse is caring for a client who experienced serious burns in a fire. Which relationship between a client's burned body surface area and fluid loss should the nurse consider when evaluating fluid loss in a client with burns?
Directly proportional
A nurse uses the same pair of gloves to remove a soiled dressing and to apply a new sterile dressing. Another nurse has observed the dressing change procedure. What initial action should the observing nurse take?
Discuss the incident with the nurse
A client sustains severe burns over 40% of the surface area of the body. The nurse is assigned to care for the client during the first 48 hours after the injury. What clinical finding does the nurse anticipate if the client develops water intoxication?
Disorientation with twitching
A client is scheduled to receive intravenous (IV) fluids to be delivered at 80 mL/hr. To adjust the drip rate when administering the IV via gravity, the nurse must determine the:
Drops per milliliter delivered by the infusion set
A client with a parotid tumor and enlarged lymph nodes in the neck is undergoing radiation therapy on an outpatient basis. For what physiologic response to the radiation should the nurse assess the client during the return visit to the radiology department?
Dysphagia
A nurse provides instruction to a client who was treated for renal colic as a result of uric acid stones. What should the nurse include in the teaching plan? Select all that apply.
Eliminate organ meats from diet. Drink two glasses of water at bedtime. Increase fluid intake to three quarts daily.
The nurse is providing care for a client who is on bed rest. The nurse can prevent skin breakdown for this client by:
Encouraging the client to move around as much as possible
The most essential nursing intervention for a client with a nephrostomy tube is to:
Ensure free drainage of urine
A client is admitted and diagnosed with myasthenia gravis. Pyridostigmine bromide (Mestinon) therapy via tablets has been prescribed. The nurse anticipates that the dosage will be changed frequently during the first week of therapy. While the dosage is being adjusted, the nurse should:
Evaluate the client's muscle strength every hour after the medication is given
A client is receiving furosemide (Lasix) to relieve edema. The nurse should monitor the client for which response to the medication?
Excessive loss of potassium ions
Before a client with syphilis can be treated, what should be determined?
Existence of allergies
A client is admitted with 50% of the body surface area burned. The nurse caring for the client 48 hours after admission reviews the client's laboratory results: urine specific gravity 1.015, urine output 50 mL/hr, hematocrit 32, albumin 3.6 g/dL, and pulmonary arterial wedge pressure 10 mm Hg. The nurse concludes that the data indicate that the:
Fluid therapy is successful
When caring for a client with a portable wound drainage system (Hemovac), the nurse takes into consideration that the physics principle underlying this drainage system is:
Fluids flow from an area of higher pressure to one of lower pressure
A nurse teaches a client who is scheduled for a kidney transplant about the need for immunosuppressive medications. The nurse determines that the client understands the teaching when the client states, "I must take these medications:
For the rest of my life."
The nurse is caring for a client with a diagnosis of acute kidney failure associated with drug toxicity. When the client complains of thirst, the nurse should offer:
Hard candy
A client is admitted to the hospital with a diagnosis of cancer of the liver with ascites and is scheduled for a paracentesis. What nursing intervention is appropriate to include in the client's plan of care?
Having the client void before the procedure
A client with chronic kidney disease is scheduled to begin peritoneal dialysis. When discussing the procedure, the nurse explains that the purpose of the dialysis is to:
Help do some of the work usually done by the kidneys
A nurse epidemiologist is responsible for wound consults at the hospital where a client has been admitted with an infected wound. The client asks, "What is the primary role of a nurse epidemiologist?" The nurse explains that the nurse epidemiologist:
Helps health care providers to control infection
The nurse is caring for a client who has been diagnosed with glomerulonephritis. What initial urinary finding supports this diagnosis?
Hematuria
A client is admitted to the hospital with partial- and full-thickness burns of the chest and face sustained while trying to extinguish a brush fire. Which is the nurse's priority concern?
Inadequate gas exchange caused by smoke inhalation
A client with diabetes who is receiving long-term corticosteroid therapy is admitted to the hospital with leg ulcers. What should the nurse expect to identify when assessing this client?
Inadequate wound healing
A client will be taking nitrofurantoin (Macrobid) 50 mg orally every evening at home to manage recurrent urinary tract infections. What instructions should the nurse give to the client?
Increase the intake of fluids.
A client with a history of benign prostatic hypertrophy asks whether cranberry juice prevents bladder infections. The nurse replies that cranberry juice may be helpful because it:
Increases acidity of the urine
After a suprapubic prostatectomy, the nurse encourages the client to walk and not sit for prolonged periods. What effect of prolonged sitting is the nurse trying to prevent?
Increases the risk for bleeding
In preparation for discharge, a client who had a total hip replacement is taught wound care by the nurse. The nurse identifies that the client understands the instructions when the client states, "I will:
Inspect the incision for healing when I change the dressing."
The nurse is caring for a client with ureteral colic. To prevent the development of renal calculi in the future, the client's plan of care should include:
Instructing the client to drink 8 to 10 glasses of water daily
The health care provider suspects a wound infection in a client who is healing from a 55% burn injury and prescribes a wound culture. When obtaining a wound culture the nurse should proceed by:
Rolling a sterile swab from the center of the wound outward.
When teaching about the dietary control of gout, the nurse evaluates that the dietary teaching is understood when the client states; "I will avoid eating:
Shellfish."
A client is diagnosed as having invasive cancer of the bladder and radiation therapy is scheduled. What should the nurse expect the client to demonstrate that indicates success of radiation therapy?
Shrinkage of the tumor on scanning
A nurse is caring for a client with the diagnosis of pemphigus vulgaris. Which expected response does the nurse need to address in the client's plan of care?
Skin lesions
The nurse is caring for a client with a 30% total body surface area burn. Which assessment finding indicates to the nurse that the client's fluid replacement is adequate?
Slowing of a previously rapid pulse rate
A nurse is caring for a client who had a skin graft applied over a full-thickness burn on the chest. Which observation of the donor site during the first 24 hours after surgery should be reported to the health care provider immediately?
Small amount of yellowish green oozing
A nurse is teaching an adult health and wellness class about bladder cancer. The nurse informs the class participants that which activities put a person at risk for bladder cancer? Select all that apply.
Smoking two packs of cigarettes a day Working with dyes and ink every day
A client with a history of excessive alcohol use develops hepatic portal hypertension and an elevated serum aldosterone level. For which complications should the nurse assess this client?
Sodium retention and fluid accumulation
A client seeks help for dealing with incontinence. A nursing intervention is to teach Kegel exercises. These exercises are often beneficial in treatment for this type of incontinence:
Stress incontinence
A nurse is administering a histamine H2 antagonist to a client who has extensive burns. The nurse explains to the client that this drug is given prophylactically during the first few weeks after extensive burns. What complication of burns will it prevent?
Stress ulcer
In teaching a class about sexually transmitted diseases, the nurse discusses signs and symptoms associated with each and effects of delaying treatment. During the discussion, gummas, which are tumors that break and ulcerate, and mental and physical disability were described. Which disease is associated with this process?
Syphyllis
A nurse's postoperative plan of care for a client who had a nephrectomy should include
Turning the client from the back to the operated side every two to three hours
A nurse is caring for a client admitted for removal of basal cell carcinoma and reconstruction of the nose. About which contributing factor should the nurse question the client when collecting a health history?
Ultraviolet radiation exposure
A client with a spinal cord injury tends to assume the low-Fowler position excessively. Click the area of the body that is most vulnerable to the development of a pressure ulcer in this client.
The sacrum bears the most pressure because it is the focal point of the weight of the body when in the low-Fowler position; also, shearing forces may cause local tissue trauma. Although other areas of the body are vulnerable, they do not bear as much body weight as the sacrum when the client is in the low-Fowler position.
A client who has repeated episodes of cystitis is scheduled for a cystoscopy to determine the possibility of urinary tract abnormalities. The client asks the nurse to describe the procedure. The nurse's most appropriate response is, "This procedure is:
The visualization of the inside of the bladder with an instrument connected to a source of light."
Before a transurethral resection of the prostate (TURP), a client asks about what to expect postoperatively. The most appropriate response by the nurse is:
There will be an indwelling urinary catheter and a continuous bladder irrigation in place."
In response to a client's question, the nurse explains the difference between partial-thickness (second-degree) burns and full-thickness (third-degree) burns. What information about partial-thickness burns should the nurse include in the discussion?
They are painful, reddened, and have blisters
A nurse is caring for a client with acute kidney failure who is receiving a protein restricted diet. The client asks why this diet is necessary. What information should the nurse include in a response to the client's questions?
This supplies only essential amino acids, reducing the amount of metabolic waste products, thus decreasing stress on the kidneys.
When assessing a client during peritoneal dialysis, a nurse observes that drainage of the dialysate from the peritoneal cavity has ceased before the required volume has returned. What should the nurse instruct the client to do?
Turn from side to side
A nurse administers trimethoprim-sulfamethoxazole (Bactrim) to a client diagnosed with a urinary tract infection. What should the nurse monitor to determine the therapeutic effectiveness of the drug?
White blood cell (WBC) count
A client who is diagnosed with sexual dysfunction makes a comment to the nurse, "Well, I guess my sex life is over." What is the most appropriate response by the nurse?
You are concerned about your sex life?"
A client with renal colic is scheduled for extracorporeal shock-wave lithotripsy. The night before the procedure, the client puts the call light on frequently and has many demands. Which would be an appropriate statement for the nurse to make?
You are facing a new experience tomorrow; tell me what concerns you have."
A client is taught how to change the dressing and how to care for a recently inserted nephrostomy tube. On the day of discharge the client states, "I hope I can handle all this at home; it's a lot to remember." The best response by the nurse is:
You seem to be nervous about going home."
A client is waiting for a kidney transplant. What explanation should the nurse include when teaching the client about the transplant?
You will require immunosuppressive drugs daily for the rest of your life."
A client with phosphate-based urinary calculi asks why aluminum hydroxide gel has been prescribed. The nurse explains that the medication decreases serum phosphorus by:
binding with phosphorus in the intestine
The nurse teaches a health class about communicable diseases and states that the virus that causes chickenpox also can cause:
Herpes zoster
A nurse is caring for an older adult who was admitted to the hospital to be treated for dehydration. While the nurse is providing discharge teaching, the client says, "What should I do about my dry skin? It is so itchy." What is the best response by the nurse?
Use a moisturizer on the skin daily to help reduce itching.
A client is admitted with cellulitis of the left leg and a temperature of 103° F. The primary health care provider prescribes intravenous (IV) antibiotics. Before instituting this therapy, the nurse should:
Determine the client's allergies-
A nurse provides discharge teaching to a client that had a total hip replacement. The client states that the plan is to go swimming at the community pool the day after discharge. How should the nurse respond?
Explain that the incision should not be immersed in water until it has healed
A farmer seeks medical care for a large crusty patch of skin on the cheek. The client states that even after using different remedies, it still bleeds easily and has not gotten better. From the client's history, the nurse suspects skin cancer because the major precipitating factor associated with skin cancer is:
Exposure to radiation
A client sustains full-thickness and deep partial-thickness burns. The client asks, "What is the difference between my full-thickness and deep partial-thickness burns?" The nurse explains that full-thickness burns:
Extend into the subcutaneous tissue; deep partial-thickness burns extend through the epidermis and involve only part of the dermis
The nurse reviews a client's medication history that includes a cholinergic medication. The client states, "I take that for some kind of urinary problem." The nurse recalls that cholinergic medications are prescribed primarily for what type of urinary condition?
Flaccid bladder
. A nurse is evaluating a client's fluid loss resulting from extensive burns. What is the most valuable blood test to use when monitoring a client's fluid loss?
Hematocrit
A client is admitted to the hospital with a ureteral calculus. The nurse expects what urinary clinical findings?
Hematuria with sharp pain when voiding
A nurse is caring for a client receiving hemodialysis for chronic kidney disease. The nurse should monitor the client for what complication?
Hepatitis B
When providing dietary instructions to a client who is being treated with continuous ambulatory peritoneal dialysis (CAPD) for chronic glomerulonephritis, the nurse should include the need for:
High-quality protein
Which is the most serious complication for which the nurse must monitor a client with kidney failure?
Hyperkalemia
A client experiences difficulty in voiding after an indwelling urinary catheter is removed. The nurse determines that this difficulty most likely is related to:
Interruption in previous voiding habits
A nurse is caring for a client with dysuria. A urinary tract infection is the presumed medical diagnosis and a urine specimen in sent to the laboratory for a culture and sensitivity examination. Which component found in the client's urine indicates the presence of a urinary tract infection?
Nitrate
The nurse would clarify which provider prescription for the client with acute kidney injury?
Normal saline 125 mL per hour continuous intravenous (IV) infusion
After surgery for cancer, a client is to receive adjuvant chemotherapy. The nurse teaches about the side effects of chemotherapy and informs the client that alopecia is:
Not permanent
A client is scheduled to receive irradiation to the chest wall after a tumor was removed from the client's lung. When teaching skin care to the client, the nurse emphasizes:
Keeping the skin dry to protect it from excoriation
A nurse is administering gold salts to a client with the diagnosis of rheumatoid arthritis. For which adverse effect of this drug should the client be monitored?
Kidney damage
A client's urine specific gravity is being measured. For what condition should the nurse conduct a focused assessment when a client's specific gravity is increased?
Low-grade fever
Three days after surgery, a client complains of pain in the calf. The nurse assesses the client and suspects thrombophlebitis. The nurse's next action should be to:
Maintain bed rest and notify the primary health care provider
After surgery, a client has a portable wound drainage system in place. What nursing intervention promotes drainage?
Maintaining compression of the drainage system.
After an abdominal cholecystectomy, a client has a T-tube attached to a collection device. On the day of surgery, at 10:30 PM, 300 mL of bile is emptied from the collection bag. At 6:30 AM the next day, the bag contains 60 mL of bile. What should the nurse consider in response to this information?
Mechanical problems may have developed with the T-tube
Twenty-four hours after a transurethral resection of the prostate, a client tells the nurse of lower abdominal discomfort. The nurse identifies that drainage from the urinary catheter has stopped. In response to this assessment finding, the nurse should:
Milk the catheter tubing
A client in a nursing home is diagnosed with urethritis. What should the nurse plan to do before initiating antibiotic therapy prescribed by the health care provider?
Obtain a urine specimen for culture and sensitivity.
A person sustains deep partial-thickness burns while working on a boat in a town marina and seeks advice from the nurse in the first aide station. The nurse encourages the client to seek medical attention but the client refuses. The nurse advises the person to go to a health care provider if:
Urinary output decreases.
A client with the diagnosis of breast cancer is scheduled to receive radiation therapy to the affected area. The nurse teaches the client about how to care for the area that will be irradiated. The nurse determines that further teaching is necessary when the client states that to avoid skin irritation and breakdown the client will:
Use an oatmeal-based lotion after each treatment
The nurse is caring for a client being treated in the emergency room for recurrent cystitis. Which instruction should the nurse include before discharge?
Void at least every 4 hours even if you do not feel the need to void.
A nurse reviews the history of a client who is hospitalized with a diagnosis of urinary calculi and identifies that which factor may have contributed to the development of the calculi?
History of hyperparathyroidism
A client develops kidney damage as a result of a transfusion reaction. What is the most significant clinical response that the nurse should assess when determining kidney damage?
Decreased urinary output
A worker is involved in an explosion of a steam pipe and receives a scalding burn to the chest and arms. The burned areas are painful, mottled red, weeping, and edematous. Which should the nurse conclude is an appropriate classification for these burns?
Deep partial-thickness
A client with acute renal failure moves into the diuretic phase after one week of therapy. For which signs during this phase should the nurse assess the client? Select all that apply.
Dehydration Hypovolemia
When a nurse is evaluating the condition of a client with burns of the upper body, a sign that indicates potential respiratory obstruction is:
Hoarse quality to the voice
A client has been admitted with a urinary tract infection. The nurse receives a urine culture and sensitivity report that reveals the client has vancomycin resistant entercoccus (VRE). After notifying the health care provider, which action should the nurse take to decrease the risk of transmission to others?
Move the client to a private room
A client with chronic kidney disease is on a restricted protein diet. The nurse provides teaching about high biologic-value (HBV) protein foods. An understanding of the rationale for this diet is demonstrated when the client states that HBV protein foods are:
Necessary to prevent muscle wasting
A client with end-stage kidney disease says to the nurse, "I heard that it is inevitable that I will need a kidney transplant. If so, which one of my kidneys will be removed?" Which is the best response by the nurse?
Neither of your kidneys will be removed unless they are infected."
What information should the nurse give the client after removal of a foley catheter?
Void in the plastic measuring hat placed in the toilet and then contact the nurse."
A client had a colostomy surgery and is learning how to care for the skin around the stoma. What should the nurse include in the teaching plan for this client?
Wash the area gently with soap and water before applying an appliance
The nurse is providing education about care of the residual limb to a client that had a below-the-elbow amputation. The teaching should include:
Washing and drying the residual limb at least once a day
A client comes to the emergency department because of minimal urinary output despite drinking adequate fluid. The client's blood pressure is 190/94 mm Hg. For what additional clinical manifestation associated with this data should the nurse assess the client?
Weight gain
A client is admitted with 50% of the body surface area burned after an industrial explosion and fire. The client's serum albumin is 1.5 g/dL, the hematocrit is 30%, the urine specific gravity is 1.025, and the serum globulin is 3 g/dL. When evaluating the client's response to fluid replacement, the nurse should prepare to administer a colloid when the:
Albumin is below 2 g/dL
A client is admitted with extensive bone and soft-tissue injuries to the leg. Sterile dressings are applied. Two days later, when removing the dressings, the nurse finds that one of the dressings has adhered to tissue in several places. To loosen the dressings, the nurse should:
Moisten the dressing with sterile saline
Twelve hours after sustaining full-thickness burns to the chest and thighs a client who is nothing by mouth (NPO) is complaining of severe thirst. The client's urinary output has been 60 mL/hr for the past 10 hours. No bowel sounds are heard. What should the nurse do?
Moisten the client's lips with a wet 4 × 4 gauze.
A nurse is developing a teaching plan for a client with lower extremity arterial disease (LEAD). The plan should include the importance of:
Securing professional treatment for any minor injuries to the extremities