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A client with right hydronephrosis and a history of renal calculi is preparing for discharge following a retrograde pyelogram. Which instruction should the nurse include in the client's discharge instructions?
- A. Use an incentive spirometer.
- B. Monitor the urinary stream for decreased output.
- C. Restrict physical activities.
- D. Report when hematuria becomes pink-tinged.
Correct Answer: B
Rationale: Monitoring urinary output detects complications like obstruction in hydronephrosis or renal calculi.
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The nurse is caring for a patient with chronic pancreatitis who reports persistent gnawing abdominal pain. What assessment data is most important for the nurse to obtain to help manage the patient's pain?
- A. Activity level of bowel sounds.
- B. Level and amount of physical activity.
- C. Eating patterns of dietary intake.
- D. Color and consistency of feces.
Correct Answer: C
Rationale: Eating patterns identify foods that exacerbate pancreatitis pain, guiding dietary modifications.
An adult client who had a gastric bypass surgery is admitted with possible anastomosis leakage. The client's abdomen is tender to touch, and the vital signs are: temperature 38.3° C, heart rate 130 beats/minute, respiratory rate 20 breaths/minute, and blood pressure 100/50 mm Hg. Which intervention is most important for the nurse to include in the client's plan of care?
- A. Monitor skin for breakdown.
- B. Strict intravenous (IV) fluid replacement.
- C. Encourage regular turning.
- D. Assess wound drainage daily.
Correct Answer: B
Rationale: Strict IV fluid replacement is critical to manage hypovolemia and prevent sepsis in suspected anastomosis leakage.
A client receives a prescription for 1 liter of lactated Ringer's intravenously (IV) to be infused over 8 hours. The IV administration set delivers 15 gtt/mL. How many mL/hr should the nurse program the infusion pump to deliver?
- A. 100 mL/hr
- B. 125 mL/hr
- C. 150 mL/hr
- D. 175 mL/hr
Correct Answer: B
Rationale: Dividing 1000 mL by 8 hours yields 125 mL/hr, the correct infusion rate.
The nurse is caring for a client who reports a sudden, severe facial numbness. The nurse observes an uneven smile with facial droop to the right side and a hand grasp strength that is weaker on the right than the left. The client denies a recent history of headaches or trauma. Which intervention should the nurse perform immediately?
- A. Maintain elevated positioning of the dependent joints on the affected side.
- B. Verify prescribed laboratory tests include prothrombin time and platelet count.
- C. Start two large-bore IV catheters and review inclusion criteria for IV fibrinolytic therapy.
- D. Administer aspirin to prevent further clot formation and platelet clumping.
Correct Answer: C
Rationale: Symptoms suggestive of a stroke require immediate initiation of IV access and evaluation for fibrinolytic therapy to restore cerebral blood flow.
A nurse is educating a patient with Type 2 diabetes mellitus and peripheral neuropathy. What advice should the nurse give?
- A. Shoes should be worn outside the house, but it is fine to be barefoot inside.
- B. Family members can assist with regular foot exams.
- C. Heating pads are useful if used on the lowest setting.
- D. Aching feet may be soaked in lukewarm water for one hour or more.
Correct Answer: B
Rationale: Family members assisting with regular foot exams helps detect early signs of injury or infection, critical for preventing complications in diabetic neuropathy.