Nokea
A 55-year-old client is admitted with a diagnosis of renal calculi. He presented with severe right flank pain, nausea, and vomiting. The most important nursing action for him at this time is:
- A. Intake and output measurement
- B. Daily weights
- C. Straining of all urine
- D. Administration of O2 therapy
Correct Answer: C
Rationale: Straining urine provides for assessment of calculi and evaluation of calculi descent through ureters and urethra.
You may also like to solve these questions
The client has been in active labor for the last 12 hours. During the last 3 hours, labor has been augmented with oxytocin because of hypoactive uterine contractions. Her physician assesses her cervix as 95% effaced, 8 cm dilated, and the fetus is at 0 station. Her oral temperature is 100.2F at this time. The physician orders that she be prepared for a cesarean delivery. In preparing the client for the cesarean delivery, which one of the following physician's orders should the RN question?
- A. Administer meperidine (Demerol) 100 mg IM 1 hour prior to the delivery.
- B. Discontinue the oxytocin infusion.
- C. Insert an indwelling Foley catheter prior to delivery.
- D. Prepare abdominal area from below the nipples to below the symphysis pubis area.
Correct Answer: A
Rationale: Meperidine crosses the placental barrier and can cause respiratory depression in the fetus, making it inappropriate for preoperative cesarean delivery.
The client is admitted with a possible myocardial infarction. The nurse would anticipate an order from the physician for which laboratory test?
- A. Creatine kinase
- B. Ammonia
- C. Myoglobin
- D. Troponin T
- E. Gamma-glutamyl transferase
- F. Bilirubin
Correct Answer: A, C, D
Rationale: Creatine kinase (A), myoglobin (C), and troponin T (D) are cardiac biomarkers elevated in myocardial infarction. Ammonia (B), gamma-glutamyl transferase (E), and bilirubin (F) are unrelated to acute cardiac events.
The nurse is caring for a client with a history of a colostomy who is experiencing leakage around the stoma. The nurse should:
- A. Apply a larger appliance
- B. Clean the stoma with alcohol
- C. Check the skin barrier fit
- D. Irrigate the colostomy
Correct Answer: C
Rationale: Leakage around a colostomy stoma often indicates a poor skin barrier fit, requiring adjustment or resizing. Larger appliances, alcohol, and irrigation do not address the issue.
The physician has ordered intravenous fluid with potassium for a client admitted with gastroenteritis and dehydration. Before adding potassium to the intravenous fluid, the nurse should:
- A. Assess the urinary output.
- B. Obtain arterial blood gases.
- C. Perform a dextrostick.
- D. Obtain a stool culture.
Correct Answer: A
Rationale: Potassium supplementation requires adequate renal function to prevent hyperkalemia. Assessing urinary output ensures the kidneys are functioning before adding potassium.
The nurse is caring for a client with a suspected stroke. Which assessment finding is most concerning?
- A. Mild headache
- B. Unilateral facial droop
- C. Slight dizziness
- D. Fatigue
Correct Answer: B
Rationale: Unilateral facial droop is a classic sign of stroke, indicating neurological deficit and requiring urgent evaluation. Headache (A), dizziness (C), and fatigue (D) are less specific.