A nurse is contributing to the plan of care for a client who has urolithiasis. Which of the following interventions should the nurse include in the plan?

Tell the client to expect a decrease in urine output.

Encourage the client to drink 3 L of fluids per day.

Provide the client with a high protein diet.

Maintain the client on bed rest.

Answer and Explanation

The Correct Answer is B

Choice A Reason: Telling the client to expect a decrease in urine output is not an appropriate intervention for a client who has urolithiasis, as it may indicate dehydration, obstruction, or infection.

Choice B Reason: Encouraging the client to drink 3 L of fluids per day is an appropriate intervention for a client who has urolithiasis, as it helps to flush out stones, prevent new stone formation, and reduce urinary concentration.

Choice C Reason: Providing the client with a high protein diet is not an appropriate intervention for a client who has urolithiasis, as it may increase uric acid and calcium excretion and promote stone formation.

Choice D Reason: Maintaining the client on bed rest is not an appropriate intervention for a client who has urolithiasis, as it may decrease renal perfusion and increase urinary stasis.

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Correct Answer is C

Explanation

Choice A Reason: Fatigue is not the priority finding for a client who has a low platelet count, as it may indicate other conditions such as anemia, infection, or depression.

Choice B Reason: Anorexia is not the priority finding for a client who has a low platelet count, as it may indicate other conditions such as nausea, pain, or anxiety.

Choice C Reason: Bleeding is the priority finding for a client who has a low platelet count, as it indicates that the client is at risk of hemorrhage and shock due to impaired blood clotting.

Choice D Reason: Fever is not the priority finding for a client who has a low platelet count, but it may indicate an infection that requires prompt treatment.

A. Keeping scissors at the bedside B. Providing good mouth care C. Deflating the balloon on a regular basis D. Monitoring IV fluid intake

Correct Answer is A

Explanation

Choice A Reason: Keeping scissors at the bedside is the most important safety intervention for this client, as it allows for quick removal of the tube in case of airway obstruction or bleeding.

Choice B Reason: Providing good mouth care is an important intervention for this client, but it is not the most important, as it helps to prevent oral infections and discomfort.

Choice C Reason: Deflating the balloon on a regular basis is not an appropriate intervention for this client, as it may cause bleeding or displacement of the tube.

Choice D Reason: Monitoring IV fluid intake is an important intervention for this client, but it is not the most important, as it helps to prevent fluid overload or dehydration.

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A nurse is contributing to the plan of care for a client who has urolithiasis. Which of the following interventions should the nurse include in the plan?

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