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 rheumatoid arthritis is prescribed a nonsteroidal anti-inflammatory drug (NSAID). Which client statement indicates a need for further teaching?
- A. I'll take the medication with food.'
- B. I should report any stomach pain.'
- C. I can take ibuprofen with this drug.'
- D. I'll monitor for bruising or bleeding.'
Correct Answer: C
Rationale: Taking ibuprofen with another NSAID increases the risk of gastrointestinal bleeding, indicating a knowledge deficit.
A client with lung cancer is being cared for by his wife at home. His pain is increasing in severity. The nurse recognizes that teaching has been effective when the wife does which of the following? Select all that apply.
- A. Administers long-acting or sustained-release oral pain formula (OxyContin) regularly around-the-clock.
- B. Administers immediate-release medication (oxycodone) for breakthrough pain.
- C. Avoids long-acting opioids due to her concern about addiction.
- D. Uses music for distraction as well as heat or cold in combination with medications.
- E. Substitutes acetaminophen (Tylenol) to avoid tolerance to the medications.
- F. Has her husband use a pain rating scale to measure the effectiveness at reaching his individual pain goal.
Correct Answer: A,B,D,F
Rationale: Effective pain management includes around-the-clock long-acting opioids (A), immediate-release opioids for breakthrough pain (B), non-pharmacologic methods like music or heat/cold (D), and using a pain scale to assess effectiveness (F). Avoiding long-acting opioids (C) or substituting acetaminophen (E) is not appropriate for severe cancer pain.
Angiotensin-converting enzyme (ACE) inhibitors may be prescribed for the client with diabetes mellitus to reduce vascular changes and possibly prevent or delay development of:
- A. Chronic obstructive pulmonary disease.
- B. Pancreatic cancer.
- C. Renal failure.
- D. Cerebrovascular accident.
Correct Answer: C
Rationale: ACE inhibitors protect against renal failure in diabetes by reducing vascular damage and proteinuria.
A client is scheduled to have an arteriogram. During the arteriogram, the client reports having nausea, tingling, and dyspnea. The nurse's immediate action should be:
- A. Administer epinephrine
- B. Inform the physician
- C. Administer oxygen
- D. Inform the client that the procedure is almost over
Correct Answer: B
Rationale: Nausea, tingling, and dyspnea during an arteriogram suggest a possible allergic reaction to the contrast dye or other complications (e.g., vasovagal response). The nurse should immediately inform the physician to evaluate and manage the situation. Administering epinephrine or oxygen requires a physician's order, and reassuring the client is inappropriate until the issue is addressed.
The nurse is monitoring a client post-insertion of a nasogastric tube for an intestinal obstruction. Which finding indicates the tube is functioning correctly?
- A. Clear, watery output.
- B. Bright red blood in the drainage.
- C. No output for 12 hours.
- D. Thick, mucus-like drainage.
Correct Answer: A
Rationale: Clear, watery output from a nasogastric tube indicates it is effectively decompressing the intestine by removing fluid and gas. Bright red blood suggests bleeding, no output may indicate a blockage, and thick drainage is not typical. CN: Physiological adaptation; CL: Evaluate