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. Potassium level of 3.0 mEq/L: Hypokalemia is a potential adverse effect of digoxin, and a

potassium level of 3.0 mEq/L is below the normal range. Low potassium levels can increase the risk of digoxin toxicity.

b. Heart rate of 66/min: A heart rate of 66/min is within the normal range. Digoxin is used to

treat conditions like atrial fibrillation, and the heart rate should be within an appropriate range for the client's condition.

c. BP of 132/82 mm Hg: Blood pressure within the normal range does not require immediate reporting in the context of digoxin administration.

d. Digoxin level of 1.2 ng/ml: The digoxin level of 1.2 ng/ml is within the therapeutic range, and it does not require immediate reporting.

A. Rest in a supine position. B. Breathe in through her nose and out through pursed lips. C. Limit fluid intake throughout the day. D. Consume a low-protein diet.

Correct Answer is B

Explanation

a. Rest in a supine position: Resting in a supine position may compromise lung expansion, and an upright position is often recommended for clients with emphysema to improve ventilation.

b. Breathe in through her nose and out through pursed lips: This technique helps maintain

positive airway pressure, preventing premature airway collapse, and can improve gas exchange in clients with emphysema.

c. Limit fluid intake throughout the day: Adequate hydration is important for maintaining

respiratory secretions in a liquefied state and is generally encouraged for clients with respiratory conditions.

d. Consume a low-protein diet: A low-protein diet is not specifically indicated for improving gas exchange in clients with emphysema. Nutrition recommendations may focus on a well-balanced diet to support overall health.

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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?