Nokea
A client is admitted to the surgical floor after having bowel surgery. The nurse observes that the client's urine output has decreased from 50 to 20 mL/hour. Which of the following is the most likely cause?
- A. Bowel obstruction.
- B. Adverse effect of opioid analgesics.
- C. Hemorrhage.
- D. Hypertension.
Correct Answer: B
Rationale: Opioid analgesics, commonly used post-surgery, can cause urinary retention by relaxing the bladder, reducing urine output. This is the most likely cause in this scenario.
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A client who has been treated for chronic open-angle glaucoma (COAG) for 5 years asks the nurse, 'How does glaucoma damage my eyesight?' The nurse's reply should be based on the knowledge that COAG:
- A. Results from chronic eye inflammation.
- B. Causes increased intraocular pressure.
- C. Leads to detachment of the retina.
- D. Is caused by decreased blood flow to the retina.
Correct Answer: B
Rationale: Chronic open-angle glaucoma causes increased intraocular pressure, which damages the optic nerve over time, leading to vision loss.
A client has entered a smoking cessation program to quit a two-pack-a-day cigarette habit. He tells the nurse that he has not smoked a cigarette for 3 weeks, but is afraid he is going to 'slip up' and smoke because of current job pressures. What would be the most appropriate reply for the nurse to make in response to the client's comments?
- A. Don't worry about it. Everybody has difficulty quitting smoking, and you should expect to as well.'
- B. If you increase your self-control, I am sure you will be able to avoid smoking.'
- C. Try taking a couple of days of vacation to relieve the stress of your job.'
- D. It is good that you can talk about your concerns. Try calling a friend when you want to smoke.'
Correct Answer: D
Rationale: This response acknowledges the client's concerns and offers a practical coping strategy (calling a friend) to manage cravings, supporting the client's efforts in smoking cessation. The other options are dismissive, overly simplistic, or impractical.
When teaching the client to care for an ileal conduit, the nurse instructs the client to empty the appliance frequently. Which of the following indicate that the client is following instructions?
- A. The skin around the stoma is red.
- B. The urine is a deep yellow.
- C. There is no odor present.
- D. The seal around the stoma is intact.
Correct Answer: C,D
Rationale: No odor and an intact seal indicate frequent emptying, preventing urine leakage and skin irritation. Red skin or deep yellow urine suggest inadequate care or dehydration.
A client post-ureteroscopy reports burning on urination. The nurse should:
- A. Encourage fluids.
- B. Administer antibiotics.
- C. Apply a heating pad.
- D. Notify the physician.
Correct Answer: A
Rationale: Burning is common post-ureteroscopy; fluids dilute urine, reducing irritation.
The nurse is teaching the client about deep-breathing techniques. Which of the following client statements indicates the need for additional education?
- A. œI will use my incentive spirometer every hour while I'm awake.'
- B. œI should place my hands lightly over my lower ribs and upper abdomen.'
- C. œI should get into a comfortable position before doing my breathing exercises.'
- D. œI should take four deep breaths and then cough deeply from the lungs.'
Correct Answer: D
Rationale: Taking four deep breaths before coughing is incorrect, as the client should perform deep breaths and cough in a sequence, typically 2-3 breaths followed by a cough, to prevent atelectasis effectively.