2
1.) A nurse is caring for a client who is postoperative following a urinary
diversion to treat bladder cancer. Which of the following interventions
should the nurse include in the plan of care?
● Empty the collection pouch when it is 2/3 full
● expect urine outflow into pouch to begin one to two days after surgery
● change the collection pouch in the early morning
● place an aspirin in the collection pouch to control odor
Rationale: The nurse should plan to change the urinary collection pouch in the
early morning when urine output is reduced.
2.) A nurse is caring for a client who has a diagnosis of renal calculi and
reports severe flank pain. Which of the following is the priority nursing
action?
● Relieve the clients pain
● Encourage the client to increase fluid intake
● Monitor the clients intake and outputs
● Strain the clients urine
Rationale: Using the urgent versus non-urgent priority-setting framework, the
nurse should consider urgent needs to be the priority because they pose a
greater threat to the client. The nurse might also need to use Maslow’s
hierarchy of needs, the ABC priority-setting framework, and/or nursing
knowledge to identify which finding is the most urgent. The pain associated
with renal calculi is severe and can lead to shock; therefore, this is the priority
action.
3.) A nurse is preparing to administer codeine 30 mg PO every 4 hr PRN to a
client for pain. The amount available is codeine oral solution 15 mg/5 mL.
How many mL should the nurse plan to administer per dose? (Fill in the
blank with the numeric value only, round the answer to the nearest
whole number, and use a leading zero if applicable. Do not use a trailing
zero.)
Correct answer 10
4.) A nurse is caring for a client who has femoral thrombophlebitis and a
prescription for enoxaparin. Which of the following actions should the
nurse take?
● Elevate the affected leg
● Place the client on bed rest
● Massage the affected leg
● Administer aspirin for discomfort
Rationale: The nurse should elevate the client's affected leg when the client is in
bed to reduce inflammation.
5.) A nurse is teaching a client who had an amputation of the left lower leg
3 days ago. Which of the following statements indicates that the client
understands how to care for the incision and his left upper leg?
This study source was downloaded by 100000848934517 from CourseHero.com on 08-11-2022 13:04:29 GMT -05:00
https://www.coursehero.com/file/81093372/A-nurse-is-caring-for-a-client-who-is-postoperative-following-a-urinary-diversion-to-treat-bladder-c/
, 2
● I should use powder inside my limb sock to keep it cool
● I will lie on my stomach for 30 min a few times a day
● I should expect some drainage with a strong odor because I had gangrene
This study source was downloaded by 100000848934517 from CourseHero.com on 08-11-2022 13:04:29 GMT -05:00
https://www.coursehero.com/file/81093372/A-nurse-is-caring-for-a-client-who-is-postoperative-following-a-urinary-diversion-to-treat-bladder-c/
1.) A nurse is caring for a client who is postoperative following a urinary
diversion to treat bladder cancer. Which of the following interventions
should the nurse include in the plan of care?
● Empty the collection pouch when it is 2/3 full
● expect urine outflow into pouch to begin one to two days after surgery
● change the collection pouch in the early morning
● place an aspirin in the collection pouch to control odor
Rationale: The nurse should plan to change the urinary collection pouch in the
early morning when urine output is reduced.
2.) A nurse is caring for a client who has a diagnosis of renal calculi and
reports severe flank pain. Which of the following is the priority nursing
action?
● Relieve the clients pain
● Encourage the client to increase fluid intake
● Monitor the clients intake and outputs
● Strain the clients urine
Rationale: Using the urgent versus non-urgent priority-setting framework, the
nurse should consider urgent needs to be the priority because they pose a
greater threat to the client. The nurse might also need to use Maslow’s
hierarchy of needs, the ABC priority-setting framework, and/or nursing
knowledge to identify which finding is the most urgent. The pain associated
with renal calculi is severe and can lead to shock; therefore, this is the priority
action.
3.) A nurse is preparing to administer codeine 30 mg PO every 4 hr PRN to a
client for pain. The amount available is codeine oral solution 15 mg/5 mL.
How many mL should the nurse plan to administer per dose? (Fill in the
blank with the numeric value only, round the answer to the nearest
whole number, and use a leading zero if applicable. Do not use a trailing
zero.)
Correct answer 10
4.) A nurse is caring for a client who has femoral thrombophlebitis and a
prescription for enoxaparin. Which of the following actions should the
nurse take?
● Elevate the affected leg
● Place the client on bed rest
● Massage the affected leg
● Administer aspirin for discomfort
Rationale: The nurse should elevate the client's affected leg when the client is in
bed to reduce inflammation.
5.) A nurse is teaching a client who had an amputation of the left lower leg
3 days ago. Which of the following statements indicates that the client
understands how to care for the incision and his left upper leg?
This study source was downloaded by 100000848934517 from CourseHero.com on 08-11-2022 13:04:29 GMT -05:00
https://www.coursehero.com/file/81093372/A-nurse-is-caring-for-a-client-who-is-postoperative-following-a-urinary-diversion-to-treat-bladder-c/
, 2
● I should use powder inside my limb sock to keep it cool
● I will lie on my stomach for 30 min a few times a day
● I should expect some drainage with a strong odor because I had gangrene
This study source was downloaded by 100000848934517 from CourseHero.com on 08-11-2022 13:04:29 GMT -05:00
https://www.coursehero.com/file/81093372/A-nurse-is-caring-for-a-client-who-is-postoperative-following-a-urinary-diversion-to-treat-bladder-c/
