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.
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Related Questions
Correct Answer is D
Explanation
a. Urinary retention: Dark amber, cloudy, and malodorous urine is not typically associated with urinary retention. Urinary retention usually results in a lower-than-normal urine output.
b. Urinary incontinence: Incontinence refers to the inability to control urine flow and does not directly cause changes in urine color, clarity, or odor.
c. Urinary frequency: Increased frequency of urination is not typically associated with dark amber, cloudy, and malodorous urine.
d. Urinary tract infection (UTI): Dark amber, cloudy, and foul-smelling urine are common signs of a urinary tract infection. The infection causes changes in the appearance and odor of urine due to the presence of bacteria and inflammatory cells.
Correct Answer is C
Explanation
A. Request an order for an antiemetic - Checking vital signs is the priority before administering any medication. Antiemetics may be considered later, but the nurse needs to assess the client's overall condition first.
B. Request a dietary consult - Assessing vital signs comes before consulting for dietary issues.
The priority is to determine the client's immediate physiological status.
C. Check the client’s vital signs - This is the correct first action as it helps to evaluate the client's cardiovascular status, especially considering the potential toxicity of digoxin in the setting of
nausea and refusal of breakfast.
D. Suggest that the client rests before eating the meal - While rest may be beneficial, assessing vital signs takes precedence to rule out any acute cardiovascular compromise.
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