Nokea
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.
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A nurse is reinforcing teaching with a client who takes furosemide and has a serum potassium level of 3.1 mEq/L. Which of the following foods should the nurse instruct the client to include in his daily diet?
- A. Cabbage.
- B. Cheddar cheese.
- C. Bananas.
- D. Potatoes.
Correct Answer: C
Rationale: Bananas are high in potassium, helping to increase serum potassium levels, which is beneficial for clients taking furosemide, a diuretic that causes potassium loss.
A nurse in the emergency department is assisting with the care of a client who is comatose. The provider suspects ketoacidosis. Which of the following findings should the nurse expect?
- A. Cheyne-Stokes breathing.
- B. Malignant hypertension.
- C. Acetone odor to breath.
- D. Blood glucose level below 40 mg/dL.
Correct Answer: C
Rationale: An acetone odor to the breath is a classic sign of diabetic ketoacidosis, occurring due to the accumulation of ketones in the blood.
A nurse is collecting data on a client who is postoperative following a transurethral resection of the prostate (TURP). The nurse should recognize which of the following findings is the priority?
- A. The client has small blood clots in his urinary catheter.
- B. The client reports a continuous urge to void.
- C. The client reports burning around the urinary catheter.
- D. The client has bright red urine in his urinary catheter.
Correct Answer: D
Rationale: Bright red urine indicates active bleeding, a serious complication requiring immediate attention to prevent hemorrhage.
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 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.