Nokea
A client post-lithotripsy asks about expected symptoms. The nurse should explain:
- A. Bruising at the site.
- B. Severe flank pain.
- C. Clear urine output.
- D. Fever above 102°F.
Correct Answer: A
Rationale: Bruising is common post-lithotripsy due to shock wave impact on tissues.
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A client with neutropenia has an absolute neutrophil count of 900. What is the client's risk of infection?
- A. Normal risk.
- B. Moderate risk.
- C. High risk.
- D. Extremely high risk.
Correct Answer: C
Rationale: An absolute neutrophil count (ANC) of 900 indicates moderate to severe neutropenia (ANC <1,000). This places the client at high risk for infection, as neutrophils are critical for fighting pathogens. Normal risk is ANC >1,500, and extremely high risk is ANC <200.
A client with iron deficiency anemia is refusing to take the prescribed oral iron medication because the medication is causing nausea. The nurse should do which of the following? Select all that apply.
- A. Suggest that the client use ginger when taking the medication.
- B. Ask the client what she thinks is causing the nausea.
- C. Tell the client to use stool softeners to minimize constipation.
- D. Offer to administer the medication by an intramuscular injection.
- E. Suggest that the client take the iron with orange juice.
Correct Answer: A,B,E
Rationale: Nausea and vomiting are common adverse effects of oral iron preparations. The nurse should first ask the client why she does not want to take the oral medication, and then suggest ways to decrease the nausea and vomiting. Ginger may help minimize the nausea and the client can try this remedy and evaluate its effectiveness. Iron should be taken on an empty stomach but can be taken with orange juice to enhance absorption and potentially reduce nausea. The client can evaluate if this helps the nausea. Stool softeners are not typically recommended for iron deficiency anemia, as constipation is better managed with a high-fiber diet. Intramuscular iron is a last resort and not appropriate unless oral administration is ineffective.
The nurse is assessing a client's nutritional status preoperatively. Which of the following observations would indicate poor nutrition in a 5-foot 7-inch female client who is 21 years of age?
- A. Poor posture.
- B. Little mass.
- C. Dull expression.
- D. Weight of 128 lb (58.1 kg).
Correct Answer: B
Rationale: Little mass in a 5'7' female suggests low body weight or muscle wasting, indicative of poor nutrition. A weight of 128 lb is within a healthy range, and poor posture or dull expression are less specific to nutritional status.
A client with a recent total knee replacement reports swelling in the operative leg. Which nursing action is most appropriate?
- A. Elevate the leg on two pillows.
- B. Apply a warm compress to the knee.
- C. Encourage immediate ambulation.
- D. Notify the healthcare provider.
Correct Answer: A
Rationale: Elevating the leg reduces swelling by promoting venous return, a standard post-surgical intervention.
The nurse is assessing a client with a recent history of an above-the-knee amputation presenting with phantom limb pain. The nurse anticipates a prescription for
- A. aripiprazole
- B. oxycodone
- C. amitriptyline
- D. hydroxyzine
Correct Answer: C
Rationale: Amitriptyline, a tricyclic antidepressant, is commonly used for neuropathic pain, including phantom limb pain, due to its effects on nerve signaling.