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A nurse is assisting with the care of a client immediately following a lumbar puncture. Which of the following actions should the nurse take? (Select all that apply.)
- A. Monitor the puncture site for hematoma.
- B. Elevate the client's head of bed.
- C. Insert a urinary catheter.
- D. Encourage fluid intake.
- E. Apply a cervical collar to the client.
Correct Answer: A,D
Rationale: Monitoring the puncture site for hematoma and encouraging fluid intake are crucial to detect complications and replenish cerebrospinal fluid, reducing the risk of post-lumbar puncture headache.
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A nurse is collecting data from a client who has pulmonary tuberculosis. Which of the following findings should the nurse expect?
- A. High fever in the early morning.
- B. Fatigue.
- C. Increased appetite.
- D. Night sweats.
Correct Answer: D
Rationale: Night sweats are a classic symptom of pulmonary tuberculosis, resulting from the body's immune response to the infection.
A nurse is collecting data from a client who has right-sided heart failure. Which of the following findings should the nurse expect?
- A. Frothy sputum.
- B. Orthopnea.
- C. Dyspnea.
- D. Peripheral edema.
Correct Answer: D
Rationale: Peripheral edema is a common finding in right-sided heart failure due to blood backup in systemic circulation, causing fluid accumulation in tissues.
A nurse is reviewing the urinalysis results of a client who reports urinary frequency and burning. Which of the following findings should the nurse report to the provider?
- A. Urine specific gravity 1.020.
- B. Microscopic hematuria.
- C. Amber yellow urine color.
- D. Absence of glucose in the urine.
Correct Answer: B
Rationale: Microscopic hematuria indicates red blood cells in the urine, suggesting possible urinary tract infection or other pathology requiring further evaluation.
A nurse is caring for a client who is 1 day postoperative following a transurethral resection of the prostate (TURP) and has a continuous bladder irrigation in place. Which of the following actions should the nurse take? (Select all that apply.)
- A. Contact the surgeon if the client reports a continual need to void.
- B. Use sterile technique when preparing the irrigation solution.
- C. Add the amount of bladder irrigation to the total output.
- D. Notify the surgeon if the urine is bright red or has large clots.
- E. Make sure the drainage tubing is patent and without obstruction.
Correct Answer: B,D,E
Rationale: Using sterile technique, notifying the surgeon for bright red urine or clots, and ensuring tubing patency are critical to prevent infection, manage bleeding, and maintain irrigation effectiveness.
A nurse is caring for a client who has a new diagnosis of urolithiasis. Which of the following risk factors should the nurse identify as contributing to this diagnosis?
- A. High-purine diet.
- B. Low levels of serum calcium.
- C. Female gender.
- D. Drinking large quantities of fluids.
Correct Answer: A
Rationale: A high-purine diet increases uric acid, forming crystals and stones, contributing to urolithiasis.