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A client recovering from extracorporeal shock wave lithotripsy for renal calculi has an ecchymotic area on the right lower back. What action should the nurse take?
- A. Administer fresh-frozen plasma.
- B. Apply an ice pack to the site.
- C. Place the client in the prone position.
- D. Obtain serum coagulation test results.
Correct Answer: B
Rationale: After extracorporeal shock wave lithotripsy, ecchymosis can occur due to bleeding into the tissues from the shock waves. Applying an ice pack helps reduce the extent and discomfort of bruising. Administering fresh-frozen plasma and obtaining coagulation test results are not necessary as ecchymosis after this procedure is common and does not indicate a bleeding disorder that requires immediate intervention. Placing the client in the prone position will not address the bleeding or bruising in this situation.
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What should the nurse do before an echocardiogram for a client who has had a myocardial infarction?
- A. Ensuring no food or drink for 4 hours before the procedure
- B. Obtaining informed consent from the client
- C. Assessing for any history of iodine or shellfish allergies
- D. Informing the client about the painless nature and duration of the procedure
Correct Answer: D
Rationale: The correct answer is to inform the client that the echocardiogram is a painless procedure that usually takes 30 to 60 minutes to complete. Echocardiography is a noninvasive, risk-free, and pain-free test that uses ultrasound to evaluate the heart's structure and motion. There is no need for special preparation before the procedure. Choices A, B, and C are incorrect because imposing nothing-by-mouth status, obtaining informed consent, and assessing for allergies to iodine or shellfish are not necessary steps before an echocardiogram.
The nurse is caring for a patient who is receiving furosemide (Lasix) and an aminoglycoside antibiotic. The nurse will be most concerned if the patient reports which symptom?
- A. Dizziness
- B. Dysuria
- C. Nausea
- D. Tinnitus
Correct Answer: D
Rationale: The correct answer is D: Tinnitus. When furosemide and an aminoglycoside antibiotic are used together, there is an increased risk of ototoxicity. Tinnitus, a ringing in the ears, is a common early sign of ototoxicity. Dizziness (choice A) is a common side effect of furosemide but not specifically related to this drug interaction. Dysuria (choice B) is painful urination and is not directly associated with this drug combination. Nausea (choice C) is a common side effect of furosemide but is not specifically indicative of ototoxicity caused by the drug interaction.
A client expresses difficulty voiding in public places. How should the nurse respond?
- A. Offer to turn on the faucet in the bathroom to help stimulate urination.
- B. Suggest a prescription for a diuretic to increase urine output.
- C. Propose moving to a room with a private bathroom to enhance comfort.
- D. Close the curtain to provide maximum privacy.
Correct Answer: D
Rationale: The nurse should prioritize the client's privacy when addressing issues related to voiding discomfort in public places. Closing the curtain in the current room would offer immediate privacy and support the client's needs. Turning on the faucet is not an evidence-based intervention for voiding difficulties. Prescribing a diuretic is not appropriate without further assessment. While moving to a room with a private bathroom might be ideal, it may not be immediately feasible, making ensuring privacy in the current setting the most appropriate action.
A client who has received sodium bicarbonate in large amounts is at risk for metabolic alkalosis. For which of the following signs and symptoms does the nurse assess this client?
- A. Disorientation and dyspnea
- B. Drowsiness, headache, and tachypnea
- C. Tachypnea, dizziness, and paresthesias
- D. Dysrhythmias and decreased respiratory rate and depth
Correct Answer: D
Rationale: The correct answer is D. A client with metabolic alkalosis may present with dysrhythmias and a decreased respiratory rate and depth as the body tries to compensate by retaining carbon dioxide. Options A, B, and C do not typically correlate with the signs and symptoms of metabolic alkalosis. Disorientation, dyspnea, drowsiness, headache, tachypnea, dizziness, and paresthesias are not commonly associated with metabolic alkalosis. Therefore, they are incorrect choices.
A client in the emergency department is severely dehydrated and is prescribed 3 L of intravenous fluid over 6 hours. At what rate (mL/hr) should the nurse set the intravenous pump to infuse the fluids? (Record your answer using a whole number.)
- A. 500 mL/hr
- B. 400 mL/hr
- C. 550 mL/hr
- D. 600 mL/hr
Correct Answer: A
Rationale: To calculate the rate of the intravenous pump, divide the total volume of fluid (3 L = 3000 mL) by the total time in hours (6 hours), which equals 500 mL/hr. The correct answer is A. Choice B (400 mL/hr) is incorrect as it would result in a slower infusion rate. Choice C (550 mL/hr) and Choice D (600 mL/hr) are incorrect as they would result in a faster infusion rate, exceeding the prescribed amount of fluid to be infused over 6 hours.