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.
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.
Nursing Test Bank
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Related Questions
Correct Answer is A
Explanation
a. Restrict oral fluids to 800 to 1,000 mL/day: Hyponatremia is a characteristic finding in SIADH, and fluid restriction is a key intervention to correct the imbalance.
b. Maintain an IV of 0.45% sodium chloride: Infusing hypertonic (3%) saline may be indicated in severe cases of hyponatremia, but the initial step is fluid restriction.
c. Ensure the client receives a 2 g/day sodium diet: Dietary sodium restriction is not the primary intervention for SIADH. Fluid restriction is more critical.
d. Administer desmopressin acetate 0.2 mg orally: Desmopressin acetate is an antidiuretic
hormone and would exacerbate the retention of water, further decreasing sodium levels. It is not the appropriate intervention for this client.
Correct Answer is D
Explanation
a. Heart rate 90/min: A heart rate of 90/min is within the normal range, and it is not an abnormal finding postoperatively.
b. Serum potassium 3.7 g/dL: The serum potassium level of 3.7 g/dL is within the normal range, and it is not an abnormal finding postoperatively.
c. Bowel sounds 10/min: Bowel sounds of 10/min are within the normal range and indicate return of bowel function postoperatively.
d. Urine output 48 m/2 hr: A urine output of 48 m/2 hr is less than the expected urine output (30 mL/hr), and it may indicate inadequate renal perfusion or function. This finding should be
reported to the provider.
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