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A nurse is reinforcing teaching for a client who has rheumatoid arthritis and a new prescription for aspirin 650 mg orally every 6 hr. The nurse should instruct the client to monitor for which of the following adverse effects of aspirin therapy?
- A. Constipation.
- B. Blurred vision.
- C. Insomnia.
- D. Bleeding.
Correct Answer: D
Rationale: Bleeding is a well-known adverse effect of aspirin due to its inhibition of platelet aggregation, increasing the risk of gastrointestinal bleeding or bruising.
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A nurse is assessing an older adult client who has a urinary tract infection (UTI). Which of the following findings should the nurse identify as unique for this age group?
- A. Confusion.
- B. Urinary retention.
- C. Incontinence.
- D. Low back pain.
Correct Answer: A
Rationale: Confusion is a unique symptom of urinary tract infections (UTIs) in older adults, often being the first or only symptom, making it a critical indicator for this age group.
A nurse is caring for a client who is 12 hours postoperative following a transurethral resection of the prostate (TURP) and has a 3-way urinary catheter with continuous irrigation. The nurse notes there has not been any urinary output in the last hour. Which of the following actions should the nurse perform first?
- A. Determine the patency of the tubing.
- B. Notify the provider.
- C. Administer a prescribed analgesic.
- D. Offer oral fluids.
Correct Answer: A
Rationale: Determining tubing patency is the first action to check for blockages, preventing complications like bladder distention.
A nurse is caring for a client who has benign prostatic hyperplasia (BPH). Which of the following findings should the nurse expect?
- A. Difficulty starting the flow of urine.
- B. Painful urination.
- C. Urge incontinence.
- D. Critically elevated prostate-specific antigen (PSA) level.
Correct Answer: A
Rationale: Difficulty starting urine flow is common in BPH due to prostate enlargement obstructing the urethra.
A nurse is collecting data from a client whose arterial blood gas values reveal a pH of 7.24, PaCO₂ of 53, and an HCO₃ of 24. The nurse should prepare to treat the client for which of the following acid-base imbalances?
- A. Metabolic acidosis.
- B. Metabolic alkalosis.
- C. Respiratory acidosis.
- D. Respiratory alkalosis.
Correct Answer: C
Rationale: Low pH (7.24) and high PaCO₂ (53) indicate respiratory acidosis due to CO₂ accumulation from inadequate ventilation.
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.