A client diagnosed with urolithiasis is being evaluated to determine the type of calculi that are present. The nurse should plan to keep which item available in the client's room to assist in this process?
- A. A urine strainer
- B. A calorie count sheet
- C. A vital signs graphic sheet
- D. An intake and output record
Correct Answer: A
Rationale: The urine is strained until the stone is passed, obtained, and analyzed. Straining the urine will catch small stones that should be sent to the laboratory for analysis. Once the type of stone is determined, an individualized plan of care for prevention and treatment is developed. Options 2, 3, and 4 are unrelated to the question.
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During the postoperative period, the client who underwent a pelvic exenteration reports pain in the calf area. What action should the nurse take?
- A. Ask the client to walk and observe the gait.
- B. Lightly massage the calf area to relieve the pain.
- C. Check the calf area for temperature, color, and size.
- D. Administer PRN morphine sulfate as prescribed for postoperative pain.
Correct Answer: C
Rationale: The nurse monitors the postoperative client for complications such as deep vein thrombosis, pulmonary emboli, and wound infection. Pain in the calf area could indicate a deep vein thrombosis. Change in color, temperature, or size of the client's calf could also indicate this complication. Options 1 and 2 could result in an embolus if in fact the client had a deep vein thrombosis. Administering pain medication for this client is not the appropriate nursing action since further assessment needs to take place.
The nurse who has been closely monitoring a child who has been exhibiting decorticate (flexor) posturing notes that the child suddenly exhibits decerebrate (extensor) posturing. The nurse interprets that this change in the child's posturing indicates what?
- A. An insignificant finding
- B. An improvement in condition
- C. Decreasing intracranial pressure
- D. Deteriorating neurological function
Correct Answer: D
Rationale: The progression from decorticate to decerebrate posturing usually indicates deteriorating neurological function and warrants primary health care provider notification. Options 1, 2, and 3 are inaccurate interpretations.
The nurse providing diet teaching to a client experiencing heart failure instructs the client to avoid which food item?
- A. Sherbet
- B. Steak sauce
- C. Apple juice
- D. Leafy green vegetables
Correct Answer: B
Rationale: Steak sauce is high in sodium. Leafy green vegetables, any juice (except tomato or V8 brand vegetable), and sherbet are all low in sodium. Clients with heart failure should monitor sodium intake.
Which arterial blood gas (ABG) values should the nurse anticipate in the client with a nasogastric tube attached to continuous suction?
- A. pH 7.25, PaCO2 55, HCO3 24
- B. pH 7.30, PaCO2 38, HCO3 20
- C. pH 7.48, PaCO2 30, HCO3 23
- D. pH 7.49, PaCO2 38, HCO3 30
Correct Answer: D
Rationale: Continuous nasogastric suction can lead to metabolic alkalosis due to the loss of gastric acid (hydrochloric acid), which reduces hydrogen ions and increases bicarbonate levels. The ABG values in option 4 (pH 7.49, PaCO2 38, HCO3 30) indicate metabolic alkalosis, with an elevated pH and high bicarbonate level, consistent with this condition. Option 1 suggests respiratory acidosis, option 2 suggests metabolic acidosis, and option 3 suggests respiratory alkalosis, none of which align with the expected acid-base imbalance from nasogastric suction.
A client is admitted to the hospital with a diagnosis of Cushing's syndrome. The nurse monitors the client for which problem that is likely to occur with this diagnosis?
- A. Hypovolemia
- B. Hypoglycemia
- C. Mood disturbances
- D. Deficient fluid volume
Correct Answer: C
Rationale: Cushing's syndrome is a metabolic disorder resulting from the chronic and excessive production of cortisol. When Cushing's syndrome develops, the normal function of the glucocorticoids becomes exaggerated and the classic picture of the syndrome emerges. This exaggerated physiological action can cause mood disturbances, including memory loss, poor concentration and cognition, euphoria, and depression. It can also cause persistent hyperglycemia along with sodium and water retention (hypernatremia), producing edema (hypervolemia; fluid volume excess), and hypertension.