Nokea
A client has renal colic due to renal lithiasis. What is the nurse's first priority in managing care for this client?
- A. I need to know the client to ingest fluids.
- B. Encourage the client to drink at least 500 mL of water each hour.
- C. Request the central supply department to send supplies for straining urine.
- D. Administer an opioid analgesic as prescribed.
Correct Answer: D
Rationale: Severe pain from renal colic is the priority, requiring opioid analgesics for immediate relief to improve client comfort and cooperation.
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Which fluid is best for a client with renal calculi?
- A. Cranberry juice.
- B. Cola.
- C. Water.
- D. Milk.
Correct Answer: C
Rationale: Water increases urine volume, reducing stone formation risk.
Which of the following lab values should the nurse report to the health care provider when the client has anemia?
- A. Schilling test result, elevated.
- B. Intrinsic factor, absent.
- C. Sedimentation rate, 16 mm per hour.
- D. Red blood cells (RBCs) within normal range.
Correct Answer: B
Rationale: An absent intrinsic factor is a critical finding in clients with anemia, as it indicates pernicious anemia, a condition where the body cannot absorb vitamin B12 due to a lack of intrinsic factor. This requires immediate medical attention and lifelong B12 supplementation. An elevated Schilling test is not a standard result (the test measures B12 absorption), a sedimentation rate of 16 mm/hour is normal, and normal RBCs do not explain anemia.
After a cholecystectomy, the client is to follow a low-fat diet. Which of the following foods would be most appropriate to include in a low-fat diet?
- A. Cheese omelet.
- B. Peanut butter.
- C. Ham salad sandwich.
- D. Roast beef.
Correct Answer: D
Rationale: A low-fat diet minimizes gallbladder workload. Roast beef (D) is leaner compared to a cheese omelet (A), peanut butter (B), or ham salad sandwich (C), which are high in fat. Thus, roast beef is the most appropriate choice.
A client is eligible for patient-controlled analgesia (PCA) when:
- A. A family member is able to assist with self-dosing.
- B. There is a court-appointed advocate to assist with self-dosing.
- C. The client has the ability to self-dose.
- D. There is a nurse to assist with self-dosing.
Correct Answer: C
Rationale: PCA requires the client to have the cognitive and physical ability to self-dose, ensuring safe and effective pain management.
The nurse is assessing a client for movement after halo traction placement for a C8 fracture. The nurse should document which of the following?
- A. The client's shoulders shrug against downward pressure of the examiner's hands.
- B. The client's arm pulls up from a resting position against resistance.
- C. The client's arm straightens out from a flexed position against resistance.
- D. The client's hand-grasp strength is equal.
Correct Answer: A
Rationale: A C8 fracture affects the lower cervical nerves, but shoulder shrug (trapezius, innervated by cranial nerve XI and C3-C4) should remain intact. Arm movements and hand grasp involve C5-C8 and may be impaired, making shoulder shrug the most reliable intact movement to document.