Nokea
A client with a history of a kidney stone is being discharged. The nurse should teach the client to:
- A. Increase fluid intake
- B. Avoid dairy products
- C. Limit protein intake
- D. Take vitamin C supplements
Correct Answer: A
Rationale: Increasing fluid intake prevents kidney stone recurrence by diluting urine and flushing crystals. Dairy, protein, and vitamin C restrictions depend on stone type but are secondary.
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The nurse assists a client with advanced emphysema to the bathroom. The client becomes extremely short of breath while returning to bed. The nurse should:
- A. Increase his nasal O2 to 6 L/min
- B. Place him in a lateral Sims' position
- C. Encourage pursed-lip breathing
- D. Have him breathe into a paper bag
Correct Answer: C
Rationale: Pursed-lip breathing helps blow off CO2 and keep air passages open, reducing shortness of breath. Increasing O2 too high may remove the breathing stimulus, and the other options are not appropriate.
A client who has been receiving Urokinase (UPA) for deep vein thrombosis is noted to have dark brown urine in the urine collection bag. Which action should the nurse take immediately?
- A. Prepare an injection of vitamin K
- B. Irrigate the urinary catheter with 50 mL of normal saline
- C. Offer the client additional oral fluids
- D. Withhold the medication and notify the physician
Correct Answer: D
Rationale: Dark brown urine may indicate hematuria, a potential side effect of Urokinase, a thrombolytic agent. The nurse should withhold the medication and notify the physician immediately to assess for bleeding complications. Vitamin K is used for warfarin reversal, irrigation is inappropriate, and fluids won’t address the issue.
A 30-year-old client has just been treated in the ER for bruises and abrasions to her face and a broken arm from domestic violence, which has been increasing in frequency and intensity over the last few months. The nurse assesses her as being very anxious, fearful, bewildered, and feeling helpless as she states, 'I don't know what to do, I'm afraid to go home.' The best response by the nurse to the client would be:
- A. I wouldn't want to go home either; call a friend who could help you.
- B. Did you do something that could have made him so angry?
- C. Let's talk about people and resources available to you so that you don't have to go home.
- D. I'll call the police and they will take care of him, and you can go home and get some rest.
Correct Answer: C
Rationale: A person in crisis needs support, assistance, and direction from a caregiver rather than just an instruction. A battered person may feel guilt and think that they cause the abuser's behavior; however, the abuser has the problem and goes through phases of violence. The nurse should provide support and guidance to the client in crisis by offering alternatives and assist in referrals. Focusing on help from law enforcement may be a very temporary solution, because the victim may be fearful of pressing charges. This answer does not address the crisis of going home.
A client with cystic fibrosis exhibits activity intolerance related to the pulmonary problems associated with his disease. However, he needs to be encouraged to participate in daily physical exercise. The ultimate aim of exercise is to:
- A. Create a sense of well-being and self-worth
- B. Help him overcome respiratory infections
- C. Establish an effective, habitual breathing pattern
- D. Promote normal growth and development
Correct Answer: C
Rationale: Physical exercise is an important adjunct to chest physiotherapy. It stimulates mucus secretion, promotes a feeling of well-being, and helps to establish a habitual breathing pattern.
The nurse is admitting a client with folic acid deficiency anemia. Which of the following questions is most important for the nurse to ask the client?
- A. Do you take aspirin on a regular basis?'
- B. Do you drink alcohol on a regular basis?'
- C. Do you eat red meat?'
- D. Have your stools been normal?'
Correct Answer: B
Rationale: Aspirin does not affect folic acid absorption. Folic acid deficiency is strongly associated with alcohol abuse. Because folic acid is a coenzyme for single carbon transfer purines, calves liver or other purines are the meat sources. Folic acid does not affect stool character.