A nurse is caring for a client who has impaired renal function. For which of the following findings should the nurse notify the provider?
Urine is cloudy after sitting in the urinal for 6 hours.
First-voided urine in the morning has a strong odor.
Urine output of 175 mL in the past 8 hours.
Urine output of 2,200 mL in the past 24 hours.
The Correct Answer is C
A. Cloudy urine may indicate sediment or the presence of protein but does not necessarily require immediate notification to the provider.
B. A strong odor in the first-voided urine can be normal or due to dehydration or dietary factors, and does not immediately warrant concern.
C. A urine output of 175 mL in 8 hours is significantly low and indicates possible oliguria, which is a concern for impaired renal function and should be reported to the provider.
D. A urine output of 2,200 mL in 24 hours can indicate normal or excessive output (polyuria), but it is less concerning than oliguria and does not require immediate notification.
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Correct Answer is ["B","D","E"]
Explanation
A. Assessing the client every 4 hours is insufficient; the nurse should assess the client more frequently to monitor for changes in condition and risk factors for falls.
B. Placing a fall-risk identification band on the client's wrist is essential for alerting all staff to the client's fall risk, thereby promoting safety.
C. Keeping the client's room dark at night increases the risk of falls; adequate lighting should be provided to help the client navigate safely.
D. Teaching the client to use the call light encourages them to seek assistance when needed, which can help prevent falls.
E. Keeping the client's bed in the lowest position minimizes the risk of injury if the client attempts to get out of bed without assistance.
Correct Answer is C
Explanation
A. Milk, eggs, and cheese are primarily sources of protein and fats, with minimal carbohydrates.
B. Chicken is a protein source, while green beans and apples provide some carbohydrates, but not at the same level as the correct answer.
C. Rice, potatoes, and oranges are all high in carbohydrates, making this the group with the highest carbohydrate content. Rice and potatoes are starchy foods, while oranges provide simple carbohydrates.
D. Butter, oils, and avocados are high in fats and contain negligible carbohydrates.