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A client with renal calculi has a stent placed. The nurse should teach:
- A. Report blood in urine.
- B. Avoid all activity.
- C. Remove the stent at home.
- D. Expect no discomfort.
Correct Answer: A
Rationale: Blood in urine may indicate stent issues, requiring medical attention.
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A client post-cystoscopy reports severe pain. The nurse should:
- A. Administer analgesics as prescribed.
- B. Encourage ambulation.
- C. Apply a cold pack.
- D. Notify the physician.
Correct Answer: D
Rationale: Severe pain post-cystoscopy is abnormal and requires physician notification to rule out complications.
The nurse is teaching the client about home blood glucose monitoring. Which of the following blood glucose measurements indicates hypoglycemia?
- A. 59 mg/dL.
- B. 75 mg/dL.
- C. 108 mg/dL.
- D. 119 mg/dL.
Correct Answer: A
Rationale: A blood glucose level of 59 mg/dL is below the normal range (<70 mg/dL) and indicates hypoglycemia, requiring immediate intervention.
The nurse is planning a home visit for a client with hepatitis. In order to prevent transmission the nurse should focus teaching on:
- A. Proper food handling.
- B. Insulin syringe disposal.
- C. Alpha-interferon.
- D. Use of condoms.
Correct Answer: D
Rationale: Hepatitis B and C are transmitted via body fluids, so condom use (D) prevents sexual transmission. Food handling (A) is key for hepatitis A, syringe disposal (B) applies to needle-sharing, and alpha-interferon (C) is a treatment, not a preventive measure.
A client with pancreatic cancer is receiving morphine via a subcutaneous pump. The client is developing drug tolerance. The nurse understands that the client is:
- A. Tolerating the medication well.
- B. Showing addiction to morphine.
- C. Requiring an increased dose.
- D. Experiencing physical dependence.
Correct Answer: C
Rationale: Drug tolerance means the client requires an increased dose to achieve the same pain relief, as the body has adapted to the current dose of morphine.
A 58-year-old male has just had a sclerosing agent instilled after chest tube drainage of a pleural effusion. The nurse should instruct the client to:
- A. Lie still to prevent a pneumothorax.
- B. Sit upright with arms on an overhead table to promote lung expansion.
- C. Change position frequently to distribute the agent.
- D. Lie on the side where the thoracentesis was done to hold pressure on the chest tube site.
Correct Answer: C
Rationale: Changing position frequently distributes the sclerosing agent evenly, promoting effective pleurodesis to prevent recurrent pleural effusion.