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A client is being admitted with a diagnosis of urolithiasis and ureteral colic. The nurse expects to note which finding on pain assessment?
- A. Dull and aching pain in the costovertebral area
- B. Aching and cramplike pain throughout the abdomen
- C. Pain that is sharp and radiating posteriorly to the spinal column
- D. Pain that is excruciating, wavelike, and radiating toward the genitalia
Correct Answer: D
Rationale: The pain of ureteral colic is caused by movement of a stone through the ureter and is sharp, excruciating, and wavelike, radiating to the genitalia and thigh. The stone causes reduced flow of urine, and the urine also contains blood because of the stone's abrasive action on urinary tract mucosa. Stones in the renal pelvis cause pain that is a dull ache in the costovertebral area. Renal colic is characterized by pain that is acute, with tenderness over the costovertebral area.
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The nurse provides information to a client diagnosed with insulin-dependent diabetes mellitus. Which manifestations resulting from a blood glucose level less than 70 mg/dL (4 mmol/L) should the nurse include in the information? Select all that apply.
- A. Hunger
- B. Sweating
- C. Weakness
- D. Nervousness
- E. Cool clammy skin
- F. Increased urinary output
Correct Answer: A,B,C,D,E
Rationale: Hypoglycemia is characterized by a blood glucose level less than 70 mg/dL (4 mmol/L). Clinical manifestations of hypoglycemia include hunger, sweating, weakness, nervousness, cool clammy skin, blurred vision or double vision, tachycardia, and palpitations. Increased urinary output is a manifestation of hyperglycemia.
The nurse is caring for a client who has been placed in skin traction. Which action by the nurse provides for countertraction to reduce shear and friction?
- A. Using a footboard
- B. Providing an overhead trapeze
- C. Slightly elevating the foot of the bed
- D. Slightly elevating the head of the bed
Correct Answer: C
Rationale: The part of the bed under an area in traction is usually elevated to aid in countertraction. For the client in skin traction (which is applied to a leg), the foot of the bed is elevated. Option 3 provides a force that opposes the traction force effectively without harming the client. A footboard, an overhead trapeze, or elevating the head of the bed is not used to provide countertraction.
A client has not ingested any food or liquids for 4 hours after two episodes of nausea and vomiting. What will the nurse offer the client initially now that she or he is no longer nauseated?
- A. Toast
- B. Gelatin
- C. Dry cereal
- D. Ginger ale
Correct Answer: D
Rationale: Clear liquids are best tolerated first after episodes of nausea and vomiting. If the client tolerates sips (20 to 30 mL at a time) of clear liquids, such as water or ginger ale (with the carbonation removed if better tolerated), then the amounts may be increased and gelatin, tea, and broth may be added. Once these are tolerated, solid foods such as toast, cereal, chicken, and other easily digested foods may be tried.
A primary health care provider prescribes acetaminophen liquid 450 mg orally every 4 hours PRN for pain. The medication label reads 160 mg/5 mL. The nurse prepares how many milliliters (mL) to administer one dose? Fill in the blank and record your answer to the nearest whole number.
Correct Answer: 14 mL
Rationale: Use the formula for calculating medication dosages. Formula: Desired × Volume / Available = mL per dose. 450 mg × 5 mL / 160 mg = 14 mL.
An assessment of a client's vocal cords requires indirect visualization of the larynx. Which instruction should the nurse give the client to facilitate this procedure?
- A. Try to swallow.
- B. Hold your breath.
- C. Breathe normally.
- D. Roll the tongue to the back of the mouth.
Correct Answer: C
Rationale: Indirect laryngoscopy is done to assess the function of the vocal cords or obtain tissue for biopsy. Observations are made during rest and phonation by using a laryngeal mirror, head mirror, and light source. The client is placed in an upright position to facilitate passage of the laryngeal mirror into the mouth and is instructed to breathe normally. Swallowing cannot be done with the mirror in place. The procedure takes longer than the time the client would be able to hold the breath, and this action is ineffective anyway. The tongue cannot be moved back because it would occlude the airway.