When preparing to measure urinary output from a client's ileal conduit, which item(s) should the nurse bring to the room? Select all that apply.

Sterile specimen cup.

Examination gloves.

Normal saline solution.

Needleless 10 mL syringe.

Drainage container.

Answer and Explanation

Correct Answer : B,E

Rationale:
A. Sterile specimen cup: A sterile cup is used for collecting urine for culture or diagnostic testing, not for routine measurement of urinary output. Measuring total output does not require sterility.

B. Examination gloves: Gloves are essential to maintain standard precautions and protect the nurse from contact with urine, which may contain pathogens. They are required for safe handling of urinary drainage systems.

C. Normal saline solution: Saline is not needed for routine measurement of urinary output from an ileal conduit. It is only used for irrigation if prescribed or if a blockage occurs.

D. Needleless 10 mL syringe: A syringe is not required to measure total urinary output. Syringes are used only for accessing ports or collecting small samples, not for emptying a drainage bag.

E. Drainage container: A calibrated container is necessary to collect and measure urine accurately from the ileal conduit. It allows quantification of urinary output, which is critical for monitoring fluid balance.

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Correct Answer is B

Explanation

Rationale:
A. These are common side effects of the vaccines and will resolve in a few days: While mild fatigue or soreness may occur after immunizations, increasing fatigue and visual changes in a patient with multiple sclerosis may indicate a disease relapse rather than routine vaccine side effects. Dismissing these symptoms could delay necessary evaluation.

B. Immunizations can trigger a relapse of the disease, so get plenty of extra rest: In individuals with multiple sclerosis, immunologic stimulation from vaccines can occasionally precipitate a relapse or exacerbate neurological symptoms. The nurse should teach the client to monitor for worsening symptoms, rest, and promptly report changes to her healthcare provider.

C. These early signs of an infection may require medical treatment with antibiotics: The symptoms described—fatigue and visual problems—are more consistent with an MS relapse than an infection. Antibiotics are not indicated unless there is clear evidence of a bacterial infection.

D. Plans to move into the dormitory need to be postponed for at least a semester: Relapse symptoms do not automatically require delaying life plans such as moving. Management should focus on monitoring, rest, and prompt evaluation rather than long-term lifestyle changes without medical guidance.

A. Craving. B. Withdrawal. C. Tolerance. D. Denial.

Correct Answer is A

Explanation

Rationale:
A. Craving: Craving refers to a strong psychological desire or urge to use a substance despite the absence of physical withdrawal symptoms. The client reports feeling physically well when abstinent but misses the habitual late-night drinking, indicating a conditioned psychological drive. This reflects the reward and habit pathways involved in substance use disorders.

B. Withdrawal: Withdrawal involves physiologic symptoms that occur when a substance is stopped, such as tremors, nausea, anxiety, or seizures with alcohol dependence. The client explicitly states that the body feels fine during abstinence. This presentation does not align with withdrawal physiology.

C. Tolerance: Tolerance is the need for increasing amounts of a substance to achieve the same effect due to neuroadaptation. The client does not describe needing more alcohol or diminished effects. The concern expressed centers on desire rather than dose escalation.

D. Denial: Denial involves minimizing or refusing to acknowledge a substance use problem or its consequences. The client openly recognizes abstinence and expresses awareness of missing alcohol. This reflects insight rather than denial.

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When preparing to measure urinary output from a client's ileal conduit, which item(s) should the nurse bring to the room? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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