Nokea
A client who is postoperative following a cholecystectomy has a urine output of 25 mL/hr. Which of the following findings should the nurse report to the provider?
- A. Abdominal pain radiating to the right shoulder.
- B. Absent bowel sounds.
- C. Brown drainage on the surgical dressing.
- D. Urine output of 25 mL/hr.
Correct Answer: D
Rationale: A urine output below 30 mL/hr indicates a potential complication, such as hypovolemia or renal impairment, and should be reported. Abdominal pain radiating to the right shoulder can be common after a cholecystectomy due to referred pain from the diaphragm, whereas absent bowel sounds may be expected temporarily postoperatively. Brown drainage on the surgical dressing is typical in the early postoperative period and may represent old blood or other normal discharge.
You may also like to solve these questions
A client is to start taking furosemide and is being taught about dietary modifications by a nurse. Which of the following foods should the nurse recommend to the client?
- A. Cabbage
- B. Bananas
- C. Carrots
- D. Potatoes
Correct Answer: B
Rationale: The correct answer is B: Bananas. Bananas are high in potassium, which helps counter the potassium-depleting effects of furosemide. Furosemide is a loop diuretic that can lead to potassium loss, so including potassium-rich foods like bananas in the diet can help maintain a healthy potassium level. Choices A, C, and D do not specifically address the potassium needs associated with furosemide therapy and are not the most appropriate recommendations in this context.
While performing assessments on newborns in the nursery, which finding should the nurse report to the provider?
- A. A two-day old newborn with a respiratory rate of 70.
- B. A 16-hour old newborn who has not passed meconium yet.
- C. A two-day old newborn with a small amount of blood-tinged vaginal discharge.
- D. A 16-hour old newborn with a blood glucose of 45 mg/dL.
Correct Answer: A
Rationale: A respiratory rate of 70 in a two-day old newborn is above the normal range and should be reported to the provider. This finding may indicate respiratory distress or another underlying issue that needs prompt attention. Choices B, C, and D are within normal limits for newborns and do not require immediate reporting to the provider.
A nurse is collecting data from a client who has myasthenia gravis (MG). Which of the following images should the nurse identify as an indication that the client is experiencing ptosis?
- A. Drooping eyelids
- B. Unequal pupils
- C. Facial twitching
- D. Facial droop
Correct Answer: A
Rationale: The correct answer is A: 'Drooping eyelids.' Ptosis, characterized by drooping of the eyelid, is a classic symptom seen in myasthenia gravis. This occurs due to muscle weakness, particularly in the muscles that control eyelid movement. Choice B, 'Unequal pupils,' is not associated with ptosis and may indicate other neurological issues. Choice C, 'Facial twitching,' is not a typical sign of ptosis but could be related to other conditions like nerve irritation. Choice D, 'Facial droop,' is more commonly seen in conditions affecting the facial nerve, like Bell's palsy, and is not a characteristic feature of myasthenia gravis.
A client with a new prescription for prednisone for the treatment of Addison's disease needs teaching. Which instruction should the nurse include?
- A. Take the medication with food
- B. Avoid taking aspirin
- C. Schedule a bone density test
- D. Expect increased appetite
Correct Answer: C
Rationale: The correct instruction for the nurse to include is to schedule a bone density test. Prednisone can lead to reduced bone density, making regular monitoring crucial for clients on long-term therapy. Instructing the client to take the medication with food (choice A) or avoid taking aspirin (choice B) are not directly related to prednisone therapy for Addison's disease. While prednisone can cause increased appetite, it is not the priority instruction in this scenario, compared to monitoring bone density (choice D).
A nurse is teaching a client who has gastroesophageal reflux disease (GERD) about ways to reduce symptoms. Which of the following instructions should the nurse include?
- A. Avoid lying down after meals
- B. Eat large meals to reduce acid production
- C. Drink carbonated beverages with meals
- D. Consume spicy foods to improve digestion
Correct Answer: A
Rationale: The correct answer is A: 'Avoid lying down after meals.' This instruction is important for clients with GERD as it helps reduce reflux symptoms. Lying down after meals can worsen GERD symptoms by allowing stomach acid to flow back into the esophagus. Choice B is incorrect because eating large meals can actually increase acid production and exacerbate GERD symptoms. Choice C is incorrect as carbonated beverages can trigger acid reflux in individuals with GERD. Choice D is also incorrect because consuming spicy foods can irritate the esophagus and lead to increased reflux symptoms.