Nokea
A client post-cystoscopy reports severe pain. The nurse should:
- A. Administer analgesics as prescribed.
- B. Encourage ambulation.
- C. Apply a cold pack.
- D. Notify the physician.
Correct Answer: D
Rationale: Severe pain post-cystoscopy is abnormal and requires physician notification to rule out complications.
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Which of the following clients with burns will most likely require an endotracheal or tracheostomy tube?
- A. Electrical burns of the hands and arms causing arrhythmias.
- B. Thermal burns to the head, face, and airway resulting in hypoxia.
- C. Chemical burns on the chest and abdomen.
- D. Secondhand smoke inhalation.
Correct Answer: B
Rationale: Thermal burns to the head, face, and airway can cause swelling and obstruction, leading to hypoxia and requiring airway management like endotracheal intubation or tracheostomy.
A client who follows a vegetarian diet was referred to a dietitian for nutritional counseling for anemia. Which client outcome indicates that the client does not understand nutritional counseling? The client:
- A. Adds dried fruit to cereal and baked goods.
- B. Cooks tomato-based foods in iron pots.
- C. Drinks coffee or tea with meals.
- D. Adds vitamin C to all meals.
Correct Answer: C
Rationale: Drinking coffee or tea with meals inhibits iron absorption due to tannins, which bind to iron and reduce its bioavailability. This indicates a lack of understanding of nutritional counseling for anemia, as the client should avoid these beverages during meals. Adding dried fruit (iron source), cooking in iron pots (increases iron content), and consuming vitamin C (enhances iron absorption) are appropriate strategies.
In addition to nausea and severe flank pain, a female client with renal calculi has pain in the groin and bladder. The nurse should assess the client further for six years of:
- A. Nephritis.
- B. Referred pain.
- C. Urine retention.
- D. Additional stone formation.
Correct Answer: B
Rationale: Groin and bladder pain in renal calculi often indicate referred pain from the stone's movement or irritation along the urinary tract.
Which of the following is an expected outcome of pursed-lip breathing for clients with emphysema?
- A. To promote oxygen intake.
- B. To strengthen the diaphragm.
- C. To strengthen the intercostal muscles.
- D. To promote carbon dioxide elimination.
Correct Answer: D
Rationale: Pursed-lip breathing prolongs exhalation, reducing air trapping and promoting CO2 elimination in emphysema. It does not directly increase oxygen intake or strengthen muscles.
The nurse is caring for a client in labor who is positive for the human immunodeficiency virus (HIV). The nurse should obtain a prescription for which medication?
- A. valacyclovir
- B. zidovudine
- C. amphotericin b
- D. metronidazole
Correct Answer: B
Rationale: Zidovudine (AZT) is used during labor in HIV-positive clients to reduce the risk of perinatal transmission of HIV. Choice A (valacyclovir) is for herpes, Choice C (amphotericin B) is for fungal infections, and Choice D (metronidazole) is for bacterial/parasitic infections.