Nokea
A nurse is collecting data from a client who has systemic lupus erythematosus. Which of the following findings is the highest priority to report to the provider?
- A. Client reports feeling depressed.
- B. Joint pain in hands and knees.
- C. Dry, raised rash on the face.
- D. Presence of peripheral edema.
Correct Answer: D
Rationale: Peripheral edema is the highest priority as it may indicate kidney involvement, a serious SLE complication requiring immediate attention.
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A nurse is admitting a client who reports recurrent flank pain and nausea for 24 hr. Which of the following actions should the nurse take first?
- A. Monitor intake and output.
- B. Administer pain medication.
- C. Ambulate in hall.
- D. Strain the urine.
Correct Answer: B
Rationale: Administering pain medication is the priority to alleviate discomfort, allowing for further assessment and treatment.
A nurse is reinforcing discharge instructions to a client who is postoperative from a hip arthroplasty. Which of the following statements by the client indicates a correct understanding of the teaching?
- A. I will avoid wearing socks on my feet.
- B. I will avoid performing leg exercises.
- C. I will avoid crossing my legs for the first 3 months after surgery.
- D. I will avoid lying on the side of my surgery when I get home.
Correct Answer: C
Rationale: Avoiding crossing the legs for the first 3 months after surgery helps prevent dislocation of the hip joint and promotes proper healing.
A nurse is contributing to the plan of care for a client who has urolithiasis. Which of the following interventions should the nurse include in the plan?
- A. Tell the client to expect a decrease in urine output.
- B. Provide the client a high protein diet.
- C. Maintain the client on bed rest.
- D. Encourage the client to drink 3 L of fluids per day.
Correct Answer: D
Rationale: Encouraging the client to drink 3 L of fluids per day helps flush out stones, prevent new stone formation, and reduce urinary concentration.
A nurse is assisting with the care of a client who has hypocalcemia. For which of the following signs should the nurse monitor?
- A. Kernig's sign.
- B. Brudzinski's sign.
- C. Chvostek's sign.
- D. Cullen's sign.
Correct Answer: C
Rationale: Chvostek's sign, facial muscle twitching when tapping the facial nerve, is a clinical sign of hypocalcemia.
A nurse is collecting data from a client who has end-stage kidney disease and is waiting for transport to dialysis. Which of the following findings should the nurse expect?
- A. Diaphoresis.
- B. Hypotension.
- C. Peripheral edema.
- D. Facial flushing.
Correct Answer: C
Rationale: Peripheral edema is common in end-stage kidney disease due to the kidneys' inability to remove excess fluid.