Nokea
A client with cirrhosis begins to develop ascites. Spironolactone (Aldactone) is prescribed to treat the ascites. The nurse should monitor the client closely for which of the following drug-related adverse effects?
- A. Constipation.
- B. Hyperkalemia.
- C. Irregular pulse.
- D. Dysuria.
Correct Answer: B
Rationale: Spironolactone is a potassium-sparing diuretic, so hyperkalemia (B) is a key adverse effect. Constipation (A), irregular pulse (C), and dysuria (D) are not typical.
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Which symptom suggests bladder cancer recurrence?
- A. Painful urination.
- B. Frequent urination.
- C. Hematuria.
- D. Nocturia.
Correct Answer: C
Rationale: Hematuria is a common sign of bladder cancer recurrence.
A client has undergone a cystectomy and an ileal conduit diversion. What should the nurse incorporate into the discharge instructions? Select all that apply.
- A. A limit of least 3,000 mL of fluid each day.
- B. Minimize daily activities.
- C. Keep urine alkaline to prevent urinary tract infections.
- D. Avoid odor-producing foods, such as onions, fish, eggs, and cheese.
- E. Wear snug clothing over the stoma to encourage urine flow into the drainage bag.
Correct Answer: A,D
Rationale: An adequate fluid intake aids in the prevention of urinary calculi and infection. Odor-producing foods should be avoided as they can affect the client's lifestyle and relationships. Minimizing activities can lead to urinary stasis, promoting infection. Alkaline urine may increase infection risk, and snug clothing is not recommended as it may irritate the stoma.
A client with colon cancer undergoes surgical removal of a segment of colon and creation of a sigmoid colostomy. What assessments by the nurse indicate the client is developing complications within the first 24 hours? Select all that apply.
- A. Coarse breath sounds auscultated bilaterally at the bases.
- B. Dusky appearance of the stoma.
- C. No drainage in the ostomy appliance.
- D. Temperature greater than 101.2°F (38.5°C).
- E. Decreased bowel sounds.
Correct Answer: B,C,D
Rationale: A dusky stoma (B) indicates poor blood supply, no drainage (C) suggests obstruction or dysfunction, and fever (D) may indicate infection, all of which are complications post-colostomy. Coarse breath sounds (A) and decreased bowel sounds (E) are not necessarily indicative of immediate complications.
The nurse should teach the client who is receiving warfarin sodium that:
- A. Partial thromboplastin time values determine the dosage of warfarin sodium.
- B. Protamine sulfate is used to reverse the effects of warfarin sodium.
- C. International Normalized Ratio (INR) is used to assess effectiveness.
- D. Warfarin sodium will facilitate clotting of the blood.
Correct Answer: C
Rationale: INR monitors warfarin's anticoagulant effectiveness, guiding dosage adjustments to prevent clotting or bleeding.
The nurse is planning to give preoperative instructions to a client who will be undergoing rhinoplasty. Which of the following instructions should be included:
- A. After surgery, nasal packing will be in place for 7 to 10 days.
- B. Normal saline nose drops will need to be administered preoperatively.
- C. The results of the surgery will be immediately obvious postoperatively.
- D. Aspirin-containing medications should not be taken for 2 weeks before surgery.
Correct Answer: D
Rationale: Aspirin can increase bleeding risk, so it should be avoided for 2 weeks before surgery. Nasal packing is typically removed within 1–3 days. Saline drops are not routinely required preoperatively. Surgical results may take weeks to months to be fully apparent due to swelling.