A client voided clear, yellow urine.

The client is dehydrated.

The client has a urinary tract infection.

The client has normal urine output.

The client has kidney stones.

Answer and Explanation

The Correct Answer is C

Choice A rationale
The client is dehydrated. Dehydration typically results in concentrated, dark yellow urine. Clear, yellow urine indicates that the client is well-hydrated and not dehydrated. Dehydration would cause the urine to be more concentrated and darker in color due to the reduced volume of water in the body.
Choice B rationale
The client has a urinary tract infection. A urinary tract infection (UTI) often causes urine to appear cloudy, foul-smelling, or tinged with blood. Clear, yellow urine is not indicative of a UTI. UTIs are usually associated with symptoms such as pain or burning during urination, frequent urination, and cloudy or bloody urine.
Choice C rationale
The client has normal urine output. Clear, yellow urine is a sign of normal urine output and indicates that the client is well-hydrated. Normal urine color ranges from pale yellow to amber, depending on the concentration of the urine. Clear, yellow urine suggests that the client is drinking an adequate amount of water and maintaining proper hydration.
Choice D rationale
The client has kidney stones. Kidney stones can cause urine to appear cloudy, pink, red, or brown due to the presence of blood. Clear, yellow urine is not indicative of kidney stones. Symptoms of kidney stones include severe pain in the back or side, blood in the urine, and frequent urination. Clear, yellow urine suggests that the client does not have kidney stones.

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Correct Answer is C

Explanation

Choice A rationale
Knowing how many popsicles are available is not relevant to the nurse’s assessment. The focus should be on the content and preparation of the popsicles to ensure they meet the clear liquid diet requirements.
Choice B rationale
The color and flavor of the gelatin used in the popsicles are not as important as ensuring the popsicles meet the clear liquid diet requirements. The nurse should focus on the preparation and content of the popsicles.
Choice C rationale
Ensuring the popsicles are completely frozen is important to adhere to the clear liquid diet recommendation. If the popsicles are not completely frozen, they may contain solid particles or ingredients that could worsen the child’s condition.
Choice D rationale
Whether the popsicles contain pulp or fruit is important to determine if they meet the clear liquid diet requirements. Popsicles with pulp or fruit do not qualify as clear liquids and could worsen the child’s condition.

A. Encourage increased fluid intake and measure urinary output every 8 hours. B. Provide comfort measures such as topical warm application and tactile massage. C. Determine client’s objective measure of pain using a numerical pain scale. D. Assist the client to ambulate as much as possible during waking hours. E. Implement a 24-hour schedule of routine administration of prescribed analgesics.

Correct Answer is ["B","C","E"]

Explanation

Choice A rationale
Encouraging increased fluid intake and measuring urinary output every 8 hours is not directly related to managing chronic pain. This intervention is more relevant for clients with conditions affecting fluid balance or renal function.
Choice B rationale
Providing comfort measures such as topical warm application and tactile massage can help alleviate chronic pain by promoting relaxation and improving blood circulation. These non- pharmacological interventions can be effective in managing pain and enhancing the client’s comfort.
Choice C rationale
Determining the client’s objective measure of pain using a numerical pain scale is essential for assessing the severity of pain and evaluating the effectiveness of pain management interventions. Accurate pain assessment is crucial for developing an appropriate plan of care.
Choice D rationale
Assisting the client to ambulate as much as possible during waking hours may not be feasible for clients with severe chronic pain. While physical activity is important, it should be balanced with the client’s pain levels and overall condition.
Choice E rationale
Implementing a 24-hour schedule of routine administration of prescribed analgesics ensures consistent pain relief and prevents breakthrough pain. Regular administration of analgesics is a key component of effective pain management for clients with chronic pain.

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A client voided clear, yellow urine.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A child has experienced several episodes of vomiting. After the nurse reviews the need to provide only clear liquids, the parent of the child reports making clear liquid popsicles out of flavored gelatin for the child. Which information should the nurse obtain about the popsicles?

Correct Answer is C

Explanation

The nurse is viewing the admission assessment of a client with chronic pain. What intervention(s) should the nurse include in the client’s plan of care? Select all that apply.

Correct Answer is ["B","C","E"]

Explanation

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