Nokea
A client with renal calculi has a history of dehydration. The nurse should:
- A. Encourage 3 L of fluid daily.
- B. Limit fluid to 1 L daily.
- C. Administer IV fluids only.
- D. Restrict activity.
Correct Answer: A
Rationale: High fluid intake (3 L) prevents stone formation by diluting urine.
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Which dietary modification is appropriate for a client with calcium oxalate stones?
- A. Increase dairy intake.
- B. Limit spinach consumption.
- C. Reduce fluid intake.
- D. Eat more red meat.
Correct Answer: B
Rationale: Spinach is high in oxalates, which contribute to calcium oxalate stone formation.
A client with a total hip replacement asks about resuming sexual activity. Which response by the nurse is most appropriate?
- A. Wait at least 3 months post-surgery.'
- B. Avoid positions that flex the hip beyond 90 degrees.'
- C. Resume when you feel no pain.'
- D. Use a soft mattress for comfort.'
Correct Answer: B
Rationale: Avoiding excessive hip flexion prevents dislocation during sexual activity post-hip replacement.
After a client who has had a laparoscopic cholecystectomy receives discharge instructions, which of the following client statements would indicate that the teaching has been successful? Select all that apply.
- A. I can resume my normal diet when I want.
- B. I need to avoid driving for about 4 weeks.
- C. I may experience some pain in my right shoulder.
- D. I should spend 2 to 3 days in bed before resuming activity.
- E. I can wash the puncture site with mild soap and water.
Correct Answer: C,E
Rationale: Right shoulder pain (C) can occur due to referred pain from diaphragmatic irritation. Washing the puncture site with mild soap and water (E) is correct for hygiene. Resuming a normal diet immediately (A) is incorrect; a low-fat diet is advised. Avoiding driving for 4 weeks (B) is excessive; 1-2 weeks is typical. Bed rest for 2-3 days (D) is unnecessary as early ambulation is encouraged.
A client's arterial blood gas values are as follows: pH, 7.31; PaO2, 80 mm Hg; PaCO2, 65 mm Hg; HCO3ˆ’, 36 mEq/L. The nurse should assess the client for?
- A. Cyanosis.
- B. Flushed skin.
- C. Irritability.
- D. Anxiety.
Correct Answer: C
Rationale: The ABG shows uncompensated respiratory acidosis (low pH, high PaCO2) with adequate oxygenation (PaO2 80). Irritability is a symptom of CO2 retention. Cyanosis requires lower PaO2. Flushed skin and anxiety are less specific.
The nurse is to administer an antibiotic to a client with burns now, but there is no medication in the client's medication box. What should the nurse do first?
- A. Inform the unit's shift coordinator.
- B. Contact the client's physician.
- C. Call the pharmacy department.
- D. Borrow the medication from another client.
Correct Answer: C
Rationale: Calling the pharmacy ensures timely delivery of the correct medication, maintaining safety and adherence to protocol. Borrowing medication is unsafe and unethical.