Nokea
A client with renal calculi is prescribed tamsulosin. The nurse explains it:
- A. Dissolves stones.
- B. Relaxes ureter muscles.
- C. Reduces urine output.
- D. Prevents infection.
Correct Answer: B
Rationale: Tamsulosin relaxes ureter muscles, aiding stone passage.
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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.
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.
A client with acute renal failure has a potassium level of 6.5 mEq/L. The nurse should prepare for:
- A. IV insulin and glucose.
- B. Oral potassium supplements.
- C. Fluid restriction.
- D. Diuretic administration.
Correct Answer: A
Rationale: Insulin and glucose shift potassium into cells, treating hyperkalemia.
A client who had an esophageal hernia repair 4 hours ago has a pulse rate of 90 bpm, respiration rate of 16/minute, blood pressure of 130/80 mm Hg, pulse oximeter of 91, and a temperature of 100.4°F (38°C). What should the nurse do first?
- A. Obtain a culture of the incision.
- B. Notify the surgeon to obtain an antibiotic order.
- C. Adjust the client to a sitting position to take deep breaths.
- D. Administer an antipyretic medication.
Correct Answer: C
Rationale: A pulse oximetry of 91 indicates mild hypoxemia. Adjusting to a sitting position and encouraging deep breaths improves oxygenation, addressing the most immediate concern.