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A client with renal calculi is being assessed by a nurse. Which question should the nurse ask?
- A. Is there a family history of this problem?
- B. Do you consume cranberry juice?
- C. Do you urinate after sexual intercourse?
- D. Do you have burning sensation during urination?
Correct Answer: A
Rationale: When assessing a client with renal calculi, it is important for the nurse to inquire about a family history of the problem. There is a genetic predisposition associated with renal stone formation, making it essential to assess if other family members have experienced renal stones. Choices B, C, and D are not directly related to renal calculi. Consuming cranberry juice is more relevant to urinary tract health, urinating after sexual intercourse is related to preventing urinary tract infections, and experiencing a burning sensation during urination is a symptom commonly associated with urinary tract infections, not renal calculi.
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A client with kidney stones from secondary hyperoxaluria requires medication. Which medication should the nurse anticipate administering?
- A. Phenazopyridine (Pyridium)
- B. Propantheline (Pro-Banthine)
- C. Tolterodine (Detrol LA)
- D. Allopurinol (Zyloprim)
Correct Answer: D
Rationale: The correct answer is D: Allopurinol (Zyloprim). Allopurinol is used to treat kidney stones caused by secondary hyperoxaluria. This medication helps prevent the formation of certain types of kidney stones. Choices A, B, and C are incorrect. Phenazopyridine (Pyridium) is given to clients with urinary tract infections, not for kidney stones. Propantheline (Pro-Banthine) is an anticholinergic medication used for treating certain gastrointestinal conditions, not kidney stones. Tolterodine (Detrol LA) is also an anticholinergic with smooth muscle relaxant properties, primarily used to treat overactive bladder conditions, not kidney stones.
A nurse performing nasopharyngeal suctioning suddenly notes the presence of bloody secretions. What should the nurse do first?
- A. Continue suctioning to remove the blood
- B. Check the degree of suction being applied
- C. Encourage the client to cough out the bloody secretions
- D. Remove the suction catheter from the client's nose and begin vigorous suctioning through the mouth
Correct Answer: B
Rationale: The correct answer is to check the degree of suction being applied (Choice B). When bloody secretions are encountered during nasopharyngeal suctioning, it is crucial to assess the situation promptly. Checking the degree of suction being applied is the first step as excessive suction pressure may be causing trauma and bleeding. Adjusting the suction pressure may be necessary to prevent further harm. Continuing suctioning to remove the blood (Choice A) or performing vigorous suctioning through the mouth (Choice D) can lead to increased trauma and worsen bleeding. Encouraging the client to cough out the bloody secretions (Choice C) is not appropriate since the client undergoing suctioning is typically unable to expectorate secretions. Therefore, the priority is to check and adjust the suction settings to ensure safe and effective suctioning.
After educating a client with stress incontinence, the nurse assesses the client's understanding. Which statement made by the client indicates a need for additional teaching?
- A. I will limit my total intake of fluids.
- B. I must avoid drinking alcoholic beverages.
- C. I must avoid drinking caffeinated beverages.
- D. I shall try to lose about 10% of my body weight.
Correct Answer: A
Rationale: The correct answer is A. Limiting fluids can worsen stress incontinence by concentrating urine and irritating tissues, leading to increased incontinence. Adequate hydration is important to maintain bladder health and function. Choices B and C are correct as avoiding alcoholic and caffeinated beverages can help reduce bladder irritation. Choice D is also correct as losing about 10% of body weight can help reduce intra-abdominal pressure, which is beneficial in managing stress incontinence.
The nurse is administering intravenous fluids to a dehydrated patient. On the second day of care, the patient's weight has increased by 2.25 pounds. The nurse would expect that the patient's fluid intake has
- A. equaled urine output.
- B. exceeded urine output by 1 L.
- C. exceeded urine output by 2.5 L.
- D. exceeded urine output by 3 L.
Correct Answer: B
Rationale: A weight gain of 1 kg, or approximately 2.2 to 2.5 lb, is generally equivalent to 1 liter (L) of fluid retained by the body. In this case, the patient's weight gain of 2.25 pounds suggests an excess fluid retention of approximately 1 liter, indicating that the patient's fluid intake has exceeded urine output by 1 liter. Choices C and D are incorrect as they overestimate the fluid excess based on the patient's weight gain. Choice A is incorrect as it implies an exact balance between fluid intake and urine output, which is not reflected in the given weight increase.
A client is experiencing diarrhea. For which acid-base disorder should the nurse assess the client?
- A. Metabolic acidosis
- B. Metabolic alkalosis
- C. Respiratory acidosis
- D. Respiratory alkalosis
Correct Answer: A
Rationale: When a client experiences diarrhea, the loss of bicarbonate-rich fluids from the body leads to a decrease in the bicarbonate levels in the blood, resulting in metabolic acidosis. Metabolic alkalosis (choice B) is characterized by an increase in bicarbonate levels, which is not typically associated with diarrhea. Respiratory acidosis (choice C) is caused by retention of carbon dioxide, while respiratory alkalosis (choice D) results from excessive exhalation of carbon dioxide, neither of which are directly related to diarrhea. Therefore, the correct answer is metabolic acidosis (choice A) in the context of diarrhea.