Nokea
A client post-extracorporeal shock wave lithotripsy should report:
- A. Mild hematuria.
- B. Severe flank pain.
- C. Clear urine.
- D. Bruising.
Correct Answer: B
Rationale: Severe flank pain may indicate a complication like hematoma or obstruction.
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The client with tuberculosis is to be discharged home with community health nursing follow-up. Of the following nursing interventions, which should have the highest priority?
- A. Offering the client emotional support.
- B. Teaching the client about the disease and its treatment.
- C. Coordinating various agency services.
- D. Assessing the client's environment for sanitation.
Correct Answer: B
Rationale: Teaching about the disease and treatment is the priority to ensure adherence to the lengthy regimen, preventing relapse or resistance. Emotional support, agency coordination, and sanitation are important but secondary.
Which of the following nursing interventions is most important in preventing postoperative complications?
- A. Progressive diet planning.
- B. Pain management.
- C. Bowel and elimination monitoring.
- D. Early ambulation.
Correct Answer: D
Rationale: Early ambulation prevents multiple complications, including deep vein thrombosis, pneumonia, and atelectasis, by promoting circulation and lung expansion.
The nurse has just admitted a 35-year-old female client who has a serum vitamin B12 concentration of 800 pg/mL. Which of the following laboratory findings should cue the nurse to focus the client history assessment on specific drug or alcohol use?
- A. Total bilirubin, 0.3 mg/dL.
- B. Serum creatinine, 0.5 mg/dL.
- C. Hemoglobin, 16 g/dL.
- D. Folate, 1.5 ng/mL.
Correct Answer: D
Rationale: A serum vitamin B12 level of 800 pg/mL is within the normal range (200–900 pg/mL), but a folate level of 1.5 ng/mL is low (normal: 2.7–17 ng/mL). Low folate levels can be associated with chronic alcohol use, as alcohol impairs folate absorption and metabolism. The nurse should assess the client's history for alcohol use, as this may contribute to the folate deficiency. The other lab values (bilirubin, creatinine, hemoglobin) are normal and do not suggest drug or alcohol use.
The client is ready for discharge after surgery for a deviated septum. Which of the following discharge instructions would be appropriate?
- A. Avoid activities that elicit Valsalva's maneuver.
- B. Take aspirin to control nasal discomfort.
- C. Avoid brushing the teeth until the nasal packing is removed.
- D. Apply heat to the nasal area to control swelling.
Correct Answer: A
Rationale: Avoiding Valsalva's maneuver (e.g., straining, heavy lifting) prevents increased pressure that could cause bleeding or disrupt the surgical site.
A 45-year-old female client with breast cancer has completed chemotherapy and reports a decreased interest in sexual activity. The nurse should:
- A. Encourage her to discuss her feelings with her partner.
- B. Suggest she resume sexual activity to improve her mood.
- C. Refer her immediately to a sexual therapist.
- D. Advise her to wait until chemotherapy effects subside.
Correct Answer: A
Rationale: Encouraging open communication with her partner allows the client to address emotional and physical factors contributing to decreased sexual interest, fostering support and understanding.