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 A

Explanation

a. Tetany: A calcium level of 8 mg/dl is low and can be associated with tetany.

b. Constipation:This is associated with hypercalcemia as opposed to hypocalcemia

c. Negative Chvostek sign: A positive Chvostek sign is associated with hypocalcemia, not hypercalcemia.

d. Elevated blood pressure: Elevated calcium levels are not typically associated with elevated blood pressure. Hypertension is not a common manifestation of hypercalcemia.

A. Instruct the client to tilt her head back when she swallows. B. Add thickener to fluids. C. Place food on the left side of the client's mouth. D. Serve food at room temperature.

Correct Answer is B

Explanation

a. Instruct the client to tilt her head back when she swallows: This action is not recommended, as it increases the risk of aspiration. Tilted head positions can lead to improper bolus control and

swallowing difficulties.

b. Add thickener to fluids: This is an appropriate intervention for a client with dysphagia, as thickened fluids are easier to control during swallowing and reduce the risk of aspiration.

c. Place food on the left side of the client's mouth: This action may not directly address the risk of aspiration associated with dysphagia and left-sided weakness.

d. Serve food at room temperature: While serving food at room temperature may be preferred for some clients, it does not directly address the safety concerns associated with dysphagia and left- sided weakness.

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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?