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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The nurse devises a teaching plan for the client with aplastic anemia. Which of the following is the most important concept to teach for health promotion and maintenance?
- A. Eat animal protein and dark green, leafy vegetables and eggs.
- B. Avoid exposure to others with acute infections.
- C. Practice yoga and meditation to decrease stress and anxiety.
- D. Get 8 hours of sleep at night and take naps during the day.
Correct Answer: B
Rationale: Aplastic anemia is characterized by bone marrow failure, leading to low blood cell counts and increased risk of infection due to neutropenia. The most important health promotion strategy is to avoid exposure to infections, as infections can be life-threatening in these clients. While nutrition, stress management, and sleep are important, infection prevention is the priority.
A client with cholecystitis continues to have severe right upper quadrant pain. The nurse obtains the following vital signs: temperature 38.4°C; pulse 114; respirations 22; blood pressure 142/90. Using the SBAR (Situation-Background-Assessment-Recommendation) technique for communication, the nurse recommends to the primary care provider for the client to receive:
- A. Hydromorphone (Dilaudid) I.V.
- B. Diltiazem (Cardizem) PO.
- C. Meperidine (Demerol) I.M.
- D. Promethazine (Phenergan).
Correct Answer: A
Rationale: Severe pain requires a potent analgesic. Hydromorphone I.V. (A) provides rapid, effective pain relief. Diltiazem (B) is for cardiac conditions, not pain. Meperidine (C) is less preferred due to side effects, and promethazine (D) is for nausea, not pain.
The nurse is preparing a continuing education course on blood transfusion reactions. The nurse recognizes which intervention would prevent an ABO incompatibility (hemolytic) transfusion error.
- A. Priming a Y-tubing blood administration set with 0.9% sodium chloride (normal saline).
- B. Ensure that the client has a patent 20-gauge peripheral vascular access device.
- C. Accurately label the client's blood specimen for crossmatching.
- D. Review the client's medication allergies.
Correct Answer: C
Rationale: Accurate labeling of the client’s blood specimen for crossmatching ensures the correct blood type is matched, preventing ABO incompatibility reactions. Priming with saline, ensuring IV access, and reviewing allergies do not directly prevent ABO mismatches.
What therapeutic outcome does the nurse expect for a client who has received a premedication of glycopyrrolate (Robinul)?
- A. Increased heart rate.
- B. Increased respiratory rate.
- C. Decreased secretions.
- D. Decreased amnesia.
Correct Answer: C
Rationale: Glycopyrrolate is an anticholinergic that reduces salivary and respiratory secretions, improving airway management during surgery.
The nurse is developing a plan of care for the client with viral hepatitis. The nurse should instruct the client to:
- A. Obtain adequate bed rest.
- B. Increase fluid intake.
- C. Follow a high-protein diet.
- D. Avoid carbohydrates.
Correct Answer: A
Rationale: Adequate bed rest (A) reduces metabolic demands and supports recovery in viral hepatitis. Increased fluids (B) are supportive but secondary. High-protein diets (C) or avoiding carbohydrates (D) are not indicated for hepatitis management.