Nokea
A client is admitted to the emergency room with renal calculi. Upon assessment, which of the following findings should the nurse expect?
- A. Bradycardia
- B. Bradypnea
- C. Severe pain
- D. Nocturia
Correct Answer: C
Rationale: Severe pain (renal colic) is the most common symptom of renal calculi, caused by the stone moving and blocking the ureter.
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A nurse is teaching a client about self-administering peritoneal dialysis. Which of the following statements by the client indicates a need for further teaching?
- A. The microwave in my kitchen can warm the solution before I use it.
- B. The catheter can become infected even with sterile precautions.
- C. The volume of the output solution should be greater than the input solution.
- D. The fluid from my abdomen will be clear or slightly yellow.
Correct Answer: A
Rationale: Microwaving can unevenly heat solution and is not recommended; solutions should be warmed using approved methods.
A client is admitted to the hospital with suspected rheumatic endocarditis. Which of the following laboratory tests would assist in confirming the diagnosis?
- A. Liver enzymes
- B. Serum albumin
- C. Throat culture
- D. Arterial blood gases
Correct Answer: C
Rationale: Throat culture can identify streptococcal infection preceding rheumatic fever/endocarditis.
The nurse is caring for a client who has a small bowel obstruction. When teaching the student nurse about this condition, the nurse will include which of the following findings that are consistent with the diagnosis? (Select all that apply).
- A. Severe fluid and electrolyte imbalance
- B. Upper abdominal distention
- C. Metabolic acidosis
- D. Projectile vomiting with a fecal odor
- E. Diarrhea or ribbon-like stools
Correct Answer: A,B,D
Rationale: These reflect SBO pathophysiology: proximal distention, fluid loss/vomiting, and metabolic derangements.
A nurse is assessing a client who has left-sided heart failure. Which of the following clinical manifestations will the nurse expect?
- A. Lower extremity edema
- B. Crackles in lung bases
- C. Jugular vein distention
- D. Ascites
Correct Answer: B
Rationale: Crackles indicate pulmonary congestion characteristic of left-sided heart failure.
A nurse is caring for a client who has an endotracheal tube and is receiving mechanical ventilation. Which of the following actions should the nurse take to reduce the risk of ventilator-associated pneumonia?
- A. Provide oral care every 4 hours and as needed
- B. Position the head of the client's bed in the flat position
- C. Turn the client every 4 hours
- D. Provide humidity by maintaining moisture within the ventilator tubing
Correct Answer: A
Rationale: Regular oral care reduces bacterial colonization that could lead to VAP.