Nokea
A client post-ureteroscopy reports burning on urination. The nurse should:
- A. Encourage fluids.
- B. Administer antibiotics.
- C. Apply a heating pad.
- D. Notify the physician.
Correct Answer: A
Rationale: Burning is common post-ureteroscopy; fluids dilute urine, reducing irritation.
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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 receives a prescription from the primary healthcare provider (PHCP) for metoprolol 5 mL intravenous (IV) push x 1 dose. The nurse should take which priority action before administering the medication?
- A. Clarify the prescription with the primary healthcare provider (PHCP)
- B. Assess vital signs
- C. Review the prescription with the pharmacist
- D. Assess the client's allergies
Correct Answer: A
Rationale: Metoprolol IV push prescriptions require clarification to ensure correct dosage and administration rate.
A client develops lymphedema after a left mastectomy with lymph node dissection. Which of the following should be included in the discharge teaching plan? Select all that apply.
- A. Do not allow blood pressures or blood draws in the affected arm.
- B. Avoid application of sunscreen on the left arm.
- C. Use an electric razor for shaving.
- D. Immobilize the left arm.
- E. Elevate the left arm.
- F. Perform hand pump exercises.
Correct Answer: A,C,E,F
Rationale: Preventing trauma (A, C), elevating the arm (E), and performing exercises (F) reduce lymphedema risk and promote lymphatic drainage. Sunscreen (B) is safe, and immobilization (D) is not recommended.
Regular oral hygiene is essential for the client who has had a stroke. Which of the following nursing measures is not appropriate when providing oral hygiene?
- A. Placing the client on the back with a small pillow under the head.
- B. Keeping portable suctioning equipment at the bedside.
- C. Opening the client's mouth with a padded tongue blade.
- D. Cleaning the client's mouth and teeth with a toothbrush.
Correct Answer: A
Rationale: Placing the client on their back increases the risk of aspiration, especially in stroke patients with impaired swallowing. Suction equipment, padded tongue blades, and toothbrushing are appropriate for safe oral hygiene.
The nurse is developing a care plan with a client who had a laryngectomy 3 days ago. The nurse should instruct the client to do which of the following to assure adequate nutrition. Select all that apply.
- A. Weigh weekly and report weight loss.
- B. When eating, sit and lean slightly forward.
- C. Have serum albumin level checked regularly.
- D. Administer enteral tube feedings as ordered.
- E. Manipulate the nasogastric tube daily.
Correct Answer: A,B,C,D
Rationale: To ensure adequate nutrition post-laryngectomy, the client should monitor weight, sit and lean forward to aid swallowing, check serum albumin for nutritional status, and use enteral feedings as ordered. Manipulating the tube is not recommended to avoid dislodgement.