Nokea
A client is admitted to the hospital with a diagnosis of renal calculi. The client is experiencing severe flank pain and nausea; the temperature is 100.6°F (38.1°C). Which of the following would be a priority outcome for this client?
- A. Prevention of urinary tract complications.
- B. Alleviation of nausea.
- C. Alleviation of pain.
- D. Maintenance of fluid and electrolyte balance.
Correct Answer: C
Rationale: Severe flank pain is the most urgent issue, making pain alleviation the priority outcome to ensure client comfort and stability.
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Which assessment is most important for a client receiving mannitol?
- A. Blood pressure.
- B. Urine output.
- C. Pain level.
- D. Pupil response.
Correct Answer: B
Rationale: Urine output is critical to monitor for mannitol's diuretic effect in reducing intracranial pressure.
What should the nurse teach a client about stoma care?
- A. Clean with hydrogen peroxide.
- B. Measure stoma size weekly.
- C. Apply adhesive remover.
- D. Change pouch every day.
Correct Answer: B
Rationale: Measuring stoma size weekly ensures proper appliance fit as swelling subsides.
A client undergoing chemotherapy tells the nurse, 'I do not want to get out of bed in the morning because I am so tired.' The nursing plan of care should include:
- A. Education on the use of Neupogen (filgrastim).
- B. Individually tailored exercise program.
- C. Weight lifting when not experiencing fatigue.
- D. Bed rest until chemotherapy is completed.
Correct Answer: B
Rationale: An individually tailored exercise program can help combat fatigue, improve energy levels, and enhance quality of life for chemotherapy patients.
Nursing responsibilities for the client with a patient-controlled analgesia (PCA) system should include:
- A. Reassuring the client that pain will be relieved.
- B. Documenting the client's response to pain medication on a routine basis.
- C. Instructing the client to continue pressing the system's button whenever pain occurs.
- D. Titrating the client's pain medication until the client is free from pain.
Correct Answer: B
Rationale: Documenting the client's response to PCA is a key nursing responsibility to monitor efficacy and safety. Reassuring complete relief, instructing to press repeatedly, or titrating to pain-free status may be unrealistic or unsafe.
A client is taking an antacid for treatment of a peptic ulcer. Which of the following statements best indicates that the client understands how to correctly take the antacid?
- A. I should take my antacid at the same time as my other medications.'
- B. I need to decrease my intake of fluids so that I don't dilute the effects of my antacid.'
- C. My antacid will be most effective if I take it whenever I experience stomach pains.'
- D. It is best for me to take my antacid 1 to 3 hours after meals.'
Correct Answer: D
Rationale: Antacids are most effective when taken 1 to 3 hours after meals, as they neutralize gastric acid during peak acid secretion. Taking antacids with other medications can interfere with absorption, and fluid intake does not need to be restricted.