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 who had a total hip replacement 2 days ago has developed an infection with a fever. The nursing diagnosis of fluid volume deficit related to diaphoresis is made. Which of the following is the most appropriate outcome?
- A. The client drinks 2,000 mL of fluid per day.
- B. The client understands how to manage the incision.
- C. The client's bed linens are changed as needed.
- D. The client's skin remains cool throughout hospitalization.
Correct Answer: A
Rationale: Drinking 2,000 mL of fluid daily addresses fluid volume deficit due to diaphoresis.
A client with Parkinson's disease needs a long time to complete her morning hygiene, but she becomes annoyed when the nurse offers assistance and refuses all help. Which action is the nurse's best initial response in this situation?
- A. Tell the client firmly that she needs assistance and help her with her care.
- B. Praise the client for her desire to be independent and give her extra time and encouragement.
- C. Tell the client that she is being unrealistic about her abilities and must accept the fact that she needs help.
- D. Suggest to the client that if she insists on self-care, she should at least modify her routine.
Correct Answer: B
Rationale: Praising independence and providing extra time respects the client's autonomy while supporting her efforts. Forcing help, labeling her unrealistic, or suggesting modifications may undermine her dignity.
A client with Graves' disease is treated with radioactive iodine (RAI) in the form of sodium iodide 131I. Which of the following statements by the nurse will explain to the client how the drug works?
- A. The radioactive iodine stabilizes the thyroid hormone levels before a thyroidectomy.'
- B. The radioactive iodine reduces uptake of thyroxine and thereby improves your condition.'
- C. The radioactive iodine slows your body's production of thyroid hormones.'
- D. The radioactive iodine destroys thyroid tissue and thyroid hormones are no longer produced.'
Correct Answer: D
Rationale: Radioactive iodine (RAI) works by destroying thyroid tissue, which reduces or eliminates the production of thyroid hormones, treating hyperthyroidism in Graves' disease.
A pulmonary artery catheter is inserted in a client with severe mitral stenosis and regurgitation. The nurse administers furosemide (Lasix) to treat pulmonary congestion and begins a Nitroprusside (Nipride) drip for afterload reduction per physician orders. The nurse notices a sudden drop in the pulmonary artery diastolic pressure and pulmonary artery wedge pressure. Which of the following has the highest priority?
- A. Assess the 12-lead EKG.
- B. Assess the blood pressure.
- C. Assess the lung sounds.
- D. Assess the urine output.
Correct Answer: B
Rationale: A sudden drop in pulmonary pressures may indicate hypotension from nitroprusside. Assessing blood pressure is the priority to ensure adequate perfusion.
Guaifenesin (Robitussin) 300 mg four times a day has been ordered as an expectorant. The dosage strength of the liquid is 200 mg/5 mL. How many milliliters should the nurse administer for each dose?
Correct Answer: 7.5 mL
Rationale: To calculate the dose: 300 mg ÷ 200 mg/5 mL = 1.5 × 5 mL = 7.5 mL per dose.