Nokea
A client has a ureteral catheter in place after renal surgery. A priority nursing action for care of the ureteral catheter would be to:
- A. Irrigate the catheter with 30 mL of normal saline every 8 hours.
- B. Ensure that the catheter is draining freely.
- C. Clamp the catheter every 2 hours for 30 minutes.
- D. Ensure that the catheter drains at least 30 mL/hour.
Correct Answer: B
Rationale: Ensuring free drainage prevents obstruction or pressure buildup, which could harm the surgical site or kidney function.
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The nurse is monitoring a client who received ketamine for anesthesia induction. Which side effect should the nurse prioritize?
- A. Hypotension.
- B. Respiratory depression.
- C. Vivid dreams or hallucinations.
- D. Bradycardia.
Correct Answer: C
Rationale: Ketamine can cause vivid dreams or hallucinations, which may distress the client during recovery. Monitoring and reassuring the client are critical to manage this psychological side effect.
During the previous few months, a 56-year-old woman felt brief twinges of chest pain while working in her garden and has had frequent episodes of indigestion. She comes to the hospital after experiencing severe anterior chest pain while raking leaves. Her evaluation confirms a diagnosis of stable angina pectoris. After stabilization and treatment, the client is discharged from the hospital. At her follow-up appointment, she is discouraged because she is experiencing pain with increasing frequency. She states that she visits an invalid friend twice a week and now cannot walk up the second flight of steps to the friend's apartment without pain. Which of the following measures that the nurse could suggest would most likely help the client prevent this problem?
- A. Visit her friend early in the day.
- B. Rest for at least an hour before climbing the stairs.
- C. Take a nitroglycerin tablet before climbing the stairs.
- D. Lie down once she reaches the friend's apartment.
Correct Answer: C
Rationale: Taking sublingual nitroglycerin before exertion (e.g., climbing stairs) prevents angina by dilating coronary arteries, increasing myocardial oxygen supply.
The nurse should be especially alert for signs and symptoms of digoxin toxicity if serum levels indicate that the client has a:
- A. Low sodium level.
- B. High glucose level.
- C. High calcium level.
- D. Low potassium level.
Correct Answer: D
Rationale: Low potassium (hypokalemia) increases the risk of digoxin toxicity by enhancing digoxin's binding to cardiac cells, leading to arrhythmias.
A client with neutropenia is at risk for sepsis. Which of the following is the earliest sign the nurse should monitor for?
- A. Hypotension.
- B. Tachycardia.
- C. Oliguria.
- D. Confusion.
Correct Answer: B
Rationale: Tachycardia is often the earliest sign of sepsis, reflecting the body's response to infection, and requires prompt monitoring in a neutropenic client.
What diet should be implemented for a client who is in the early stages of cirrhosis?
- A. High-calorie, high-carbohydrate.
- B. High-protein, low-fat.
- C. Low-fat, low-protein.
- D. High-carbohydrate, low-sodium.
Correct Answer: A
Rationale: A high-calorie, high-carbohydrate diet (A) supports energy needs in early cirrhosis without overloading the liver. High-protein (B) risks encephalopathy, low-fat, low-protein (C) is too restrictive, and low-sodium (D) is for later stages with ascites.