Nokea
A client with a history of cystitis is admitted to the hospital with a diagnosis of pyelonephritis. The nurse should assess the client for which of the following?
- A. Suprapubic pain.
- B. Dysuria.
- C. Urine retention.
- D. Costovertebral tenderness.
Correct Answer: D
Rationale: Costovertebral tenderness is a hallmark of pyelonephritis, indicating kidney involvement, unlike the other symptoms, which are more typical of cystitis.
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The charge nurse on the postpartum unit has received report about a client with a fetal demise who has just delivered and will be ready for transfer out of Labor and Delivery in about 2 hours. The client has asked her primary nurse if she can stay on the unit since she found support from the nursing staff there. What action should the charge nurse on the postpartum unit take?
- A. Request a room for this client on a unit without newborns.
- B. Ask the nurse in labor and delivery to discharge the mother as soon as she is physically able to leave.
- C. Talk to the mother first and decide on a location that is mutually agreeable.
- D. Admit the mother to a private room on the postpartum unit.
Correct Answer: A
Rationale: Placing the client on a unit without newborns minimizes emotional distress from being near other newborns after a fetal demise.
Which statement about referrals is accurate?
- A. Referrals complement the healthcare teams' abilities to provide optimal care to the client.
- B. Referrals simply allow the client to be discharged into the community with the additional care they need.
- C. Nurses facilitate referrals to only the resources within the facility.
Correct Answer: A
Rationale: Referrals enhance the healthcare team's ability to provide comprehensive care by connecting clients to specialized services, not limited to discharge or internal resources .
Which of the following sounds should the nurse expect to hear when percussing a distended bladder?
- A. Hyperresonance.
- B. Tympany.
- C. Dullness.
- D. Flatness.
Correct Answer: C
Rationale: A distended bladder produces a dull percussion sound due to its fluid-filled nature, unlike the resonant or tympanic sounds of air-filled structures.
The nurse includes which interventions in the plan of care for a newborn diagnosed with gastroschisis? Select all that apply.
- A. Place infant in an open crib.
- B. Maintain intravenous site and fluids.
- C. Plan time for parents to hold the infant.
- D. Position infant in a side-lying position with a blanket roll to support the viscera.
- E. Keep exposed viscera covered with sterile moistened saline gauze and plastic wrap.
Correct Answer: B,D,E
Rationale: Gastroschisis is an abdominal wall defect in which the viscera are outside the abdominal cavity and not covered with a sac. The infant is kept nothing by mouth (NPO) so that the intravenous (IV) site and fluids are maintained. The infant should be placed in a side-lying position and the viscera supported with a blanket roll to prevent vascular compromise to a torqued intestine. Before surgery, the exposed viscera should be kept covered with sterile moistened saline gauze and plastic wrap. Thermoregulation is critical, so the infant should be placed in a warmer crib, not an open crib. The movement of the infant should be minimized, so parents are not allowed to hold the infant before surgery.
A client has soft wrist restraints to prevent her from pulling out her nasogastric tube. Which of the following nursing interventions should be implemented while the restraints are on the client?
- A. Instruct the client not to move while the restraints are in place
- B. Remove the restraints every 4 hours to provide skin care
- C. Secure the restraints to side rails of the bed
- D. Check on the client every 30 minutes while the restraints are on
Correct Answer: D
Rationale: Checking the client every 30 minutes ensures safety, circulation, and skin integrity while restraints are in use. Restraints should be removed every 2 hours for care, not 4, and securing to side rails is unsafe.