Nokea
A client with renal calculi has hematuria. The nurse should:
- A. Monitor urine output.
- B. Notify the physician immediately.
- C. Restrict fluids.
- D. Apply ice to the flank.
Correct Answer: A
Rationale: Hematuria is expected with renal calculi; monitoring ensures no excessive bleeding.
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A client with deep vein thrombosis (DVT) has an edematous right lower extremity. The client lies on her right side frequently. Rubor is noted on the lateral aspect of the right ankle. From the data collected, the appropriate nursing diagnosis for this client would be:
- A. Activity intolerance related to complaints of pain in lower right extremity
- B. Ineffective health maintenance related to lack of knowledge about DVT
- C. Pain related to edema
- D. Risk for impaired skin integrity
Correct Answer: D
Rationale: Edema, frequent lying on the right side, and rubor (redness) indicate pressure and poor circulation, increasing the risk for skin breakdown. Risk for impaired skin integrity is the most appropriate nursing diagnosis. Activity intolerance, ineffective health maintenance, and pain are less specific to the data.
The nurse is preparing to transfuse fresh frozen plasma (FFP) to a client. Which of the following actions would be appropriate for the nurse to take?
- A. Obtain baseline platelet count
- B. Verify ABO compatibility
- C. Infuse over two to four hours
- D. Obtain a 12-lead electrocardiogram
Correct Answer: B
Rationale: FFP requires ABO compatibility verification to prevent transfusion reactions, as it contains plasma proteins and antibodies. Platelet counts are irrelevant to FFP, infusion time is typically 30–60 minutes, and an ECG is not routinely required.
The nurse is assessing the client's use of medications. Which of the following medications may cause a complication with the treatment plan of a client with diabetes?
- A. Aspirin.
- B. Steroids.
- C. Sulfonylureas.
- D. Angiotensin-converting enzyme (ACE) inhibitors.
Correct Answer: B
Rationale: Steroids can increase blood glucose levels, complicating diabetes management by causing hyperglycemia.
Which of the following nursing assessment findings indicates hypovolemic shock in a client who has had a 15% blood loss?
- A. Pulse rate less than 60 bpm.
- B. Respiratory rate of 4 breaths/minute.
- C. Pupils unequally dilated.
- D. Systolic blood pressure less than 90 mm Hg.
Correct Answer: D
Rationale: A 15% blood loss can cause hypovolemic shock, with early signs including hypotension (systolic BP <90 mm Hg) due to reduced circulating volume. Bradycardia, low respiratory rate, and unequal pupils are not typical findings.
What should the nurse teach a client about stoma care?
- A. Clean with hydrogen peroxide.
- B. Measure stoma size weekly.
- C. Apply adhesive remover.
- D. Change pouch every day.
Correct Answer: B
Rationale: Measuring stoma size weekly ensures proper appliance fit as swelling subsides.