Nokea
A client has cystitis. The nurse should further assess the client for:
- A. Flank pain.
- B. Oliguria.
- C. Nausea and vomiting.
- D. Foul-smelling urine.
Correct Answer: D
Rationale: Foul-smelling urine is a common symptom of cystitis due to bacterial infection. Flank pain and oliguria are more indicative of pyelonephritis.
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A 57-year-old Hispanic woman with breast cancer who does not speak English is admitted for a lumpectomy. Her daughter, who speaks English, accompanies her. In order to obtain admission information from the client, what should the nurse do?
- A. Add the client's daughter to serve as an interpreter.
- B. Ask one of the Hispanic nursing assistants to serve as an interpreter.
- C. Use the limited Spanish learned in high school along with nonverbal communication.
- D. Obtain a trained medical interpreter.
Correct Answer: D
Rationale: A trained medical interpreter is required to ensure safety, accuracy of history data, and client confidentiality. The medical interpreter knows the client's rights and is familiar with the client's culture. Using the family member as interpreter violates the client's confidentiality. Using the nursing assistant or limited Spanish and nonverbal communication reduces the accuracy of interpretation and back-translation into English.
The nurse is caring for a client who has just undergone a nephrectomy. Which of the following interventions is most important in the immediate postoperative period?
- A. Monitor urine output.
- B. Encourage early ambulation.
- C. Administer oral fluids immediately.
- D. Keep the client on bed rest for 48 hours.
Correct Answer: A
Rationale: Monitoring urine output is critical post-nephrectomy to assess the function of the remaining kidney.
Which site or technique would you expect to use to administer ferrous sulfate?
- A. A subcutaneous injection site
- B. The PQRST technique
- C. The Z track technique
- D. The sublingual site
Correct Answer: C
Rationale: The Z-track technique is used for ferrous sulfate IM injections to prevent leakage and skin staining.
The nurse is teaching a client with a new diagnosis of type 2 diabetes mellitus about dietary modifications. Which of the following foods should the client limit?
- A. Whole grains.
- B. Sugary beverages.
- C. Lean proteins.
- D. Non-starchy vegetables.
Correct Answer: B
Rationale: Sugary beverages should be limited in type 2 diabetes to prevent blood glucose spikes.
A client who has a history of chronic ulcerative colitis is diagnosed with anemia. The nurse interprets that which factor is most likely responsible for the anemia?
- A. Blood loss
- B. Intestinal hookworm
- C. Intestinal malabsorption
- D. Decreased intake of dietary iron
Correct Answer: A
Rationale: The client with chronic ulcerative colitis is most likely anemic as a result of chronic blood loss in small amounts that occurs with exacerbations of the disease. These clients often have bloody stools and are at increased risk for anemia. There is no information in the question to support options 2 or 4. In ulcerative colitis, the large intestine is involved, not the small intestine, where vitamin B12 and folic acid are absorbed.