A nurse is reinforcing teaching with a client prior to a cytoscopy. Which of the following
statements should the nurse make? - ANS"Expect to have pink-tinged urine after this
procedure."
Rationale:
A cytoscopy is a procedure in which a scope is inserted into the urethra to diagnose or treat
bladder problems. Following the procedure, pink-tinged urine is expected.
A nurse is caring for a client who is receiving peritoneal dialysis. The nurse should monitor the
client for which of the following adverse effects. - ANSRespiratory distress
Rationale:
Respiratory distress can occur during peritoneal dialysis due to fluid overload.
A nurse is collecting data from a client who is receiving continuous ambulatory peritoneal
dialysis. Which of the following findings should the nurse report to the provider? - ANSCloudy,
yellow drainage
Rationale:
Cloudy drainage is an early manifestations of peritonitis and the nurse should report this finding
to the provider. Other manifestations include fever and abdominal tenderness.
The nurse is collecting data from a client who is postoperative following extracorporeal
shockwave lithotripsy (ESWL). The nurse should identify that which of the following findings is
the priority? - ANSReport of palpitations
Rationale:
The nurse should apply the ABC priority-setting framework. This framework emphasizes the
basic core of human functioning- having an open airway, being able to breathe in adequate
amounts of oxygen, and circulating oxygen to the body's organs via the blood. An alteration in
any of these can indicate a threat to life, and is the nurse's priority concern. When applying the
ABC priority-setting framework, airway is always the highest priority because the airway must be
clear and open for oxygen exchange to occur. Circulation is the third-highest priority in the ABC
priority-setting framework because delivery of oxygen to critical organs only occurs if the heart
and blood vessels are capable of efficiently carrying oxygen to them. ESWL is the application of
found, laser, or dry shock wave energies to break a kidney stone into small pieces. The shock
waves are initiated during the R wave of the ECG to prevent dysrhythmia. When using the
airway, breathing, circulation approach to client care, the nurse should determine report of
palpitations is a manifestation of dysrhythmias and is the priority finding.
, A nurse is reinforcing teaching about collecting a 24-hour urine specimen for creatinine
clearance with a newly licensed nurse. Which of the following instructions should the nurse
include? - ANSPlace signs in the bathroom as a reminder about the test in progress.
Rationale:
The nurse should place signs in the bathroom and alert family members of the test in progress
so that everyone saves the specimens appropriately throughout the test.
A nurse is reinforcing teaching with a client who is preoperative prior to a transurethral resection
of the prostate (TURP). Which of the following statements indicates an understanding of the
information? - ANS"I will feel the urge to urinate following this procedure."
Rationale:
After a TURP, the client will feel the urge to urinate. The nurse should reassure him that he will
receive analgesics to help relieve this discomfort.
A nurse is reinforcing dietary teaching with a client who has late-stage chronic kidney disease
(CKD). Which of the following nutrients should the nurse instruct the client to increase in her
diet? - ANSCalcium
Rationale:
A client who has CKD can develop hypocalcemia due to the reduced production of active
vitamin D, which is needed for calcium absorption. The client should supplement her diet with
dietary calcium.
A nurse is reinforcing teaching with a newly licensed nurse about caring for a client who has a
new left arteriovenous fistula. Which of the following statements should the nurse make? -
ANS"Avoid taking blood pressure on the client's left arm."
Rationale:
The nurse should avoid taking blood pressure measurements on the client's left arm, which can
decrease blood flow and cause clotting.
A nurse is caring for a client who is receiving peritoneal dialysis. The nurse notes that the
dialysate output is less than the input, and the client's abdomen is distended. Which of the
following actions should the nurse take? - ANSChange the client's position
Rationale:
The client is retaining the dialysate solution after the dwell time. The nurse should ensure that
the clamp is open and the tubing is not kinked, and reposition the client to facilitate the drainage
of the solution from the peritoneal cavity.