Question

A nurse is teaching a client who is preoperative for a renal biopsy. Which of the following statements should the nurse make?

Answer 1

Correct Answers:

"You will need to be on bed rest following the procedure."

Rationale :

🩺 Bed rest following a renal biopsy is the correct teaching because the procedure involves inserting a needle into the kidney, creating a risk for bleeding and hematoma formation.

🩺 After the biopsy, the client is usually instructed to remain on bed rest for several hours to reduce movement and allow the biopsy site to seal.

🩺 The nurse should monitor for complications such as:

🩸 Hematuria (blood in urine)
🩸 Flank or abdominal pain
⬇️ Decreased blood pressure
❤️ Increased heart rate

🩺 Monitoring vital signs and urine output is important because internal bleeding may occur after the procedure.

🩺 Activity restrictions help reduce strain on the kidney and lower the risk of hemorrhage.

🩺 This answer is correct because post-biopsy rest is essential to prevent bleeding complications.

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Answer 2

Correct Answers:

Hematuria

Rationale :

🩸 Hematuria (blood in the urine) is the expected manifestation of bladder trauma following a motor-vehicle crash.

🩸 The bladder is a hollow organ that can be injured during blunt abdominal or pelvic trauma, especially when the bladder is full at the time of impact.

🩸 Damage to the bladder wall or blood vessels can cause blood to enter the urine, resulting in gross or microscopic hematuria.

🩸 Other possible signs of bladder injury include lower abdominal pain, difficulty voiding, decreased urine output, and urinary leakage.

🩸 The nurse should recognize hematuria after trauma as a concerning finding that requires further evaluation.

🩸 Prompt identification helps prevent complications such as urinary leakage into surrounding tissues and infection.

🩸 This answer is correct because blood in the urine is a classic sign of urinary tract injury after trauma.

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Answer 3

Correct Answers:

"Avoid taking blood pressure on the client's left arm."

Rationale :

🩸 Avoiding blood pressure measurements on the left arm is the correct teaching because the client has a new left arteriovenous fistula, which is the access site for hemodialysis.

🩸 A blood pressure cuff can compress the fistula, decrease blood flow, and potentially damage the vascular access.

🩸 The AV fistula must be protected from pressure, trauma, and procedures such as:

Blood pressure measurements
Blood draws
IV insertions

🩸 Maintaining fistula patency is essential because the client will rely on this access for future hemodialysis treatments.

🩸 The nurse should teach the client to report signs of fistula problems, such as absence of vibration (thrill), swelling, pain, redness, or coolness of the extremity.

🩸 This answer is correct because protecting the fistula arm prevents complications and preserves dialysis access.

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Answer 4

Correct Answers:

Peritonitis

Rationale :

🩺 Peritonitis is the major adverse effect the nurse should monitor for in a client receiving peritoneal dialysis because the dialysis solution enters the peritoneal cavity through a catheter.

🩺 Bacteria can enter through the catheter site or during exchanges, causing inflammation and infection of the peritoneum.

🩺 The nurse should assess for signs of peritonitis, including:

🩺 Cloudy dialysate drainage
🤕 Abdominal pain or tenderness
🌡️ Fever
🤢 Nausea or vomiting

🩺 Strict aseptic technique during exchanges is essential to prevent infection.

🩺 Early recognition and treatment are important because peritonitis can lead to serious complications and loss of dialysis access.

🩺 This answer is correct because infection of the peritoneal cavity is the most common serious complication of peritoneal dialysis.

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Answer 5

Correct Answers:

"I will use a vaginal douche daily."

Rationale :

🚻 The statement “I will use a vaginal douche daily” indicates the client needs additional teaching because douching can increase the risk of urinary tract infections (UTIs).

🚻 Vaginal douching can disrupt the normal protective bacteria of the vagina and alter the natural pH balance.

🚻 This disruption allows harmful bacteria to multiply and migrate toward the urethra, increasing the likelihood of infection.

🚻 Clients with recurrent UTIs should avoid vaginal douching and use gentle hygiene practices instead.

🚻 The nurse should teach the client to clean the external genital area only and avoid products that may irritate the urinary tract.

🚻 Preventing UTIs focuses on maintaining normal flora, adequate hydration, and regular bladder emptying.

🚻 This answer is correct because daily douching can contribute to urinary tract infections rather than prevent them.

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Answer 6

Correct Answers:

Relieve the client's pain.

Rationale :

🪨 Relieving the client's pain is the priority nursing action because renal calculi (kidney stones) often cause severe, acute flank pain (renal colic) due to obstruction and ureteral spasms.

🪨 Pain from kidney stones can be sudden, intense, and debilitating, requiring prompt pain management to improve comfort and reduce stress responses.

🪨 The nurse should administer prescribed analgesics and assess the client’s pain level frequently to evaluate effectiveness.

🪨 Although hydration, urine monitoring, and straining urine are important parts of renal calculi care, they are secondary after addressing severe acute pain.

🪨 Once pain is controlled, the nurse can continue interventions to promote stone passage and identify the type of stone for treatment planning.

🪨 Prompt pain relief improves the client’s ability to participate in care and prevents unnecessary suffering.

🪨 This answer is correct because severe uncontrolled pain is the priority problem requiring immediate intervention.

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Answer 7

Correct Answers:

Limit fluid intake.

Rationale :

🩺 Limiting fluid intake is an important instruction for many clients with chronic kidney disease (CKD) because damaged kidneys cannot effectively remove excess fluid from the body.

🩺 Fluid restriction helps prevent fluid overload, which can lead to complications such as hypertension, edema, shortness of breath, and heart failure.

🩺 The amount of fluid allowed depends on the client’s kidney function, urine output, and stage of CKD.

🩺 The nurse should teach the client to monitor fluid intake and report signs of fluid retention, such as swelling or rapid weight gain.

🩺 Dietary management in CKD focuses on reducing substances the kidneys cannot adequately eliminate.

🩺 This answer is correct because fluid restriction helps prevent accumulation of excess fluid in clients with impaired kidney function.

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Answer 8

Correct Answers:

Back pain

Rationale :

🚻 Back pain is a manifestation the nurse should include when teaching about urinary tract infections (UTIs), especially if the infection progresses to the kidneys (pyelonephritis).

🚻 A lower UTI commonly causes symptoms such as dysuria, urinary frequency, urgency, and suprapubic discomfort.

🚻 When bacteria travel upward from the bladder to the kidneys, the client may develop flank or back pain, fever, chills, and systemic symptoms.

🚻 Back or flank pain can indicate a more serious infection requiring prompt evaluation and treatment.

🚻 The nurse should teach clients to report worsening symptoms, especially fever, chills, or flank pain.

🚻 This answer is correct because back pain may indicate kidney involvement from a UTI.

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Answer 9

Correct Answers:

Dysrhythmias

Rationale :

🫀 Dysrhythmias are the priority finding during extracorporeal shockwave lithotripsy (ESWL) because the shock waves used to break kidney stones can interfere with the heart’s electrical activity.

🫀 ESWL is often synchronized with the client’s cardiac rhythm to reduce the risk of cardiac complications.

🫀 New or worsening dysrhythmias can decrease cardiac output and become life-threatening, requiring immediate intervention.

🫀 The nurse should closely monitor the client’s ECG during the procedure and report any abnormal rhythm changes.

🫀 Maintaining cardiac stability is the priority because it affects circulation and organ perfusion.

🫀 This answer is correct because cardiac rhythm changes are a potentially serious complication requiring immediate attention.

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Answer 10

Correct Answers:

Check the client's electrolyte values.

Rationale :

🩺 Checking the client's electrolyte values is the priority action because the client is in the oliguric-anuric stage of acute kidney injury (AKI), when the kidneys have a reduced ability to excrete electrolytes.

🩺 The client’s symptoms of palpitations, muscle tingling, and weakness suggest a possible electrolyte imbalance, especially hyperkalemia.

🩺 Hyperkalemia is a common and potentially life-threatening complication of AKI because excess potassium can interfere with cardiac conduction and cause dangerous dysrhythmias.

🩺 The nurse should immediately assess potassium and other electrolyte levels to determine the severity of the imbalance and guide treatment.

🩺 Early recognition of hyperkalemia allows interventions such as medication therapy, dietary changes, or dialysis if needed.

🩺 Monitoring electrolytes is a priority in AKI because impaired renal function affects the body’s ability to maintain fluid and electrolyte balance.

🩺 This answer is correct because the client is showing signs of a possible electrolyte abnormality that may threaten cardiac function.

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QLexNursing

1 :
A nurse is teaching a client who is preoperative for a renal biopsy. Which of the following statements should the nurse make?

2 :
A nurse is assessing a client who was brought to the emergency department following a motor-vehicle crash. The nurse should recognize that which of the following findings is a manifestation of bladder trauma?

3 :
A nurse is teaching 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?

4 :
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?

5 :
A nurse is providing teaching to a client who has a history of urinary tract infections (UTIs). Which of the following statements should indicate to the nurse the need for additional teaching?

6 :
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?

7 :
A nurse is teaching a client who has chronic kidney disease (CKD). Which of the following instructions should the nurse include?

8 :
A nurse is teaching a client about urinary tract infections (UTIs). Which of the following manifestations should the nurse include?

9 :
A nurse is monitoring a client who is undergoing extracorporeal shockwave lithotripsy (ESWL). The nurse should identify that which of the following findings is the priority?

10 :
A nurse is caring for a client who is in the oliguric-anuric stage of acute kidney injury. The client reports diarrhea, a dull headache, palpitations, and muscle tingling and weakness. Which of the following actions should the nurse take first?

QLexNursing

1 : A nurse is teaching a client who is preoperative for a renal biopsy. Which of the following statements should the nurse make?

2 : A nurse is assessing a client who was brought to the emergency department following a motor-vehicle crash. The nurse should recognize that which of the following findings is a manifestation of bladder trauma?

3 : A nurse is teaching 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?

4 : 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?

5 : A nurse is providing teaching to a client who has a history of urinary tract infections (UTIs). Which of the following statements should indicate to the nurse the need for additional teaching?

6 : 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?

7 : A nurse is teaching a client who has chronic kidney disease (CKD). Which of the following instructions should the nurse include?

8 : A nurse is teaching a client about urinary tract infections (UTIs). Which of the following manifestations should the nurse include?

9 : A nurse is monitoring a client who is undergoing extracorporeal shockwave lithotripsy (ESWL). The nurse should identify that which of the following findings is the priority?

10 : A nurse is caring for a client who is in the oliguric-anuric stage of acute kidney injury. The client reports diarrhea, a dull headache, palpitations, and muscle tingling and weakness. Which of the following actions should the nurse take first?

1 :
A nurse is teaching a client who is preoperative for a renal biopsy. Which of the following statements should the nurse make?

2 :
A nurse is assessing a client who was brought to the emergency department following a motor-vehicle crash. The nurse should recognize that which of the following findings is a manifestation of bladder trauma?

3 :
A nurse is teaching 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?

4 :
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?

5 :
A nurse is providing teaching to a client who has a history of urinary tract infections (UTIs). Which of the following statements should indicate to the nurse the need for additional teaching?

6 :
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?

7 :
A nurse is teaching a client who has chronic kidney disease (CKD). Which of the following instructions should the nurse include?

8 :
A nurse is teaching a client about urinary tract infections (UTIs). Which of the following manifestations should the nurse include?

9 :
A nurse is monitoring a client who is undergoing extracorporeal shockwave lithotripsy (ESWL). The nurse should identify that which of the following findings is the priority?

10 :
A nurse is caring for a client who is in the oliguric-anuric stage of acute kidney injury. The client reports diarrhea, a dull headache, palpitations, and muscle tingling and weakness. Which of the following actions should the nurse take first?