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After an inguinal herniorrhaphy, the nurse should assess the client carefully for which of the following likely complications?
- A. Pneumonia.
- B. Deep vein thrombosis.
- C. Paralytic ileus.
- D. Urine retention.
Correct Answer: D
Rationale: Urine retention is a likely complication after inguinal herniorrhaphy due to anesthesia, pain, or surgical manipulation near the bladder. Pneumonia, deep vein thrombosis, and paralytic ileus are less specific to this surgery. CN: Physiological adaptation; CL: Analyze
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Which of the following adverse effects would the nurse expect the client to exhibit in the event of too rapid an infusion of TPN solution?
- A. Negative nitrogen balance.
- B. Circulatory overload.
- C. Hypoglycemia.
- D. Hypokalemia.
Correct Answer: B
Rationale: Too rapid an infusion of TPN can cause circulatory overload due to the high volume and osmolarity of the solution. Negative nitrogen balance, hypoglycemia, or hypokalemia are not directly caused by rapid infusion. CN: Pharmacological and parenteral therapies; CL: Analyze
A client has been admitted with acute renal failure. What should the nurse do? Select all that apply.
- A. Elevate the head of the bed 30 to 45 degrees.
- B. Take vital signs.
- C. Establish an I.V. access site.
- D. Call the admitting physician for orders.
- E. Contact the hemodialysis unit.
Correct Answer: B,C,D
Rationale: Taking vital signs, establishing IV access, and contacting the physician are immediate actions to assess and stabilize the client with acute renal failure.
The nurse is teaching a client how to manage a nosebleed. Which of the following instructions would be appropriate to give the client?
- A. Tilt your head backward and pinch your nose.
- B. Lie down flat and place an ice compress over the bridge of the nose.
- C. Blow your nose gently with your neck
- D. Sit down, lean forward, and pinch the soft portion of your nose.
Correct Answer: D
Rationale: Sitting and leaning forward while pinching the soft portion of the nose compresses the bleeding site and prevents blood from flowing down the throat. Tilting backward can cause swallowing of blood. Lying flat is not recommended. Blowing the nose can worsen bleeding.
When conducting a health history with a female client with thyrotoxicosis, the nurse should ask about which of the following changes in the menstrual cycle?
- A. Dysmenorrhea.
- B. Metrorrhagia.
- C. Oligomenorrhea.
- D. Menorrhagia.
Correct Answer: C
Rationale: Thyrotoxicosis increases metabolism, which can lead to decreased menstrual flow or oligomenorrhea (infrequent menstruation). Dysmenorrhea (painful periods), metrorrhagia (irregular bleeding), and menorrhagia (heavy bleeding) are less commonly associated with thyrotoxicosis.
Which stone type is associated with acidic urine?
- A. Calcium oxalate.
- B. Uric acid.
- C. Struvite.
- D. Cystine.
Correct Answer: B
Rationale: Uric acid stones form in acidic urine, requiring alkalinization.