A nurse is planning care for a client who has renal stones and a urinary catheter in place.
Which of the following interventions should the nurse include in the plan of care?

Maintain the client on bed rest.

Strain the client's urine through a mesh filter.

Encourage fluid intake of 1500 mL/day.

Clamp the urinary catheter every 2 hr.

Answer and Explanation

The Correct Answer is B

a. Maintain the client on bed rest: While rest may be indicated in some cases, it is not a specific intervention for managing renal stones with a urinary catheter.

b. Strain the client's urine through a mesh filter: Straining urine is essential to collect any stones that may have passed, allowing for analysis and identification.

c. Encourage fluid intake of 1500 mL/day: Adequate fluid intake is crucial to prevent stone formation, but the amount may vary depending on the client's specific needs and condition.

d. Clamp the urinary catheter every 2 hr: Clamping the urinary catheter is not a standard

intervention for managing renal stones. Straining the urine for stone collection is a more relevant intervention.

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Correct Answer is C

Explanation

a. Slow: Atrial fibrillation is characterized by an irregular heart rate, but it may not necessarily be slow. The rate can vary, and it is irregularly irregular.

b. Not palpable: While atrial fibrillation can result in an irregularly irregular pulse, it is not necessarily indicative of a pulse that is not palpable.

c. Irregular: Atrial fibrillation is associated with an irregularly irregular pulse due to the chaotic and disorganized atrial activity.

d. Bounding: Bounding pulses are characterized by a forceful and strong pulse, which is not typically associated with atrial fibrillation.

A. Inspiratory stridor B. Expiratory wheeze C. Coarse crackles D. Absence of breath sounds.

Correct Answer is D

Explanation

A. Inspiratory stridor - This is associated with upper airway obstruction and is not indicative of a pneumothorax.

B. Expiratory wheeze - Wheezing is commonly associated with lower airway conditions such as asthma or chronic obstructive pulmonary disease (COPD), not pneumothorax.

C. Coarse crackles - Coarse crackles are typically heard in conditions such as pneumonia or pulmonary edema, not pneumothorax.

D. Absence of breath sounds - This is a key manifestation of a pneumothorax. The air in the pleural space can prevent the lung from fully expanding, leading to the absence of breath sounds on the affected side.

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A nurse is planning care for a client who has renal stones and a urinary catheter in place.Which of the following interventions should the nurse include in the plan of care?

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A nurse is planning care for a client who has renal stones and a urinary catheter in place.
Which of the following interventions should the nurse include in the plan of care?