Nokea
After teaching a client with bacterial cystitis who is prescribed phenazopyridine (Pyridium), the nurse assesses the client's understanding. Which statement made by the client indicates a correct understanding of the teaching?
- A. I will not take this drug with food or milk.
- B. If I suspect pregnancy, I will discontinue the drug.
- C. An orange color in my urine should not alarm me.
- D. I will consume two glasses of cranberry juice daily.
Correct Answer: C
Rationale: The correct answer is C. Phenazopyridine commonly discolors urine to a deep reddish orange, which can be mistaken for blood. It is important for the client to understand that this color change is an expected side effect and should not be a cause for alarm. Additionally, the urine can stain clothing. There are no dietary restrictions or precautions related to food or milk intake while taking phenazopyridine. Stopping the medication if suspecting pregnancy is not necessary as phenazopyridine is safe to use during pregnancy. Drinking cranberry juice is not directly related to the use of phenazopyridine and is not a specific instruction given for managing bacterial cystitis.
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When working with a large population of African-American clients at a community health center, which priority assessment should a nurse include?
- A. Measure height and weight.
- B. Assess blood pressure.
- C. Observe for any signs of abuse.
- D. Ask about medications.
Correct Answer: B
Rationale: Assessing blood pressure is the priority assessment when working with a population of African-American clients due to the high prevalence of hypertension in this group. African Americans have a higher risk of hypertension, which can lead to complications like end-stage renal disease. Monitoring blood pressure allows for the early detection and management of hypertension. While measuring height and weight, observing for signs of abuse, and asking about medications are important assessments, assessing blood pressure is crucial in this context to address the specific health needs of African-American clients.
A client is vomiting. For which acid-base imbalance does the nurse assess the client?
- A. Metabolic acidosis
- B. Metabolic alkalosis
- C. Respiratory acidosis
- D. Respiratory alkalosis
Correct Answer: B
Rationale: In a client who is vomiting, the loss of gastric fluid containing hydrochloric acid can lead to metabolic alkalosis. Metabolic alkalosis is caused by the loss of acids such as hydrochloric acid from the body. Therefore, in this scenario, the nurse should assess the client for metabolic alkalosis. Choices A, C, and D are incorrect because vomiting does not typically lead to metabolic acidosis, respiratory acidosis, or respiratory alkalosis.
A nurse reviews a client's urinalysis report. Which finding does the nurse recognize as abnormal?
- A. pH of 6.0
- B. An absence of protein
- C. The presence of ketones
- D. Specific gravity of 1.018
Correct Answer: C
Rationale: The correct answer is C. The presence of ketones in the urine is abnormal. Ketones in the urine may indicate a state of ketosis, which is commonly seen in uncontrolled diabetes, fasting, or a low-carbohydrate diet. A normal pH range of urine is 4.5 to 7.8, making a pH of 6.0 within the normal range. An absence of protein is a normal finding in urine, as proteinuria (presence of protein) is abnormal. A specific gravity of 1.018 falls within the normal range of 1.016 to 1.022. Therefore, the presence of ketones is the abnormal finding in this scenario.
A client with chronic kidney disease (CKD) is experiencing nausea, vomiting, visual changes, and anorexia. Which action by the nurse is best?
- A. Check the client's digoxin (Lanoxin) level.
- B. Administer an anti-nausea medication.
- C. Ask if the client can eat crackers.
- D. Refer the client to a gastrointestinal specialist.
Correct Answer: A
Rationale: In a client with chronic kidney disease experiencing symptoms like nausea, vomiting, visual changes, and anorexia, it is crucial for the nurse to suspect digoxin (Lanoxin) toxicity. These symptoms are indicative of digoxin toxicity. Therefore, the best action for the nurse to take is to check the client's digoxin level. Administering anti-nausea medication, asking about eating crackers, and referring to a gastrointestinal specialist may help with symptom management but do not address the underlying cause of the symptoms, which is digoxin toxicity in this case.
After educating a client with a history of renal calculi, the nurse assesses the client's understanding. Which statement made by the client indicates a correct understanding of the teaching?
- A. I should drink at least 3 liters of fluid every day.
- B. I will eliminate all dairy or sources of calcium from my diet.
- C. Aspirin and aspirin-containing products can lead to stones.
- D. The doctor can give me antibiotics at the first sign of a stone.
Correct Answer: A
Rationale: To prevent the formation of renal calculi, it is essential to maintain adequate hydration as dehydration can contribute to the precipitation of minerals leading to stone formation. Therefore, the correct statement indicating understanding of the teaching is choice A. Increasing fluid intake helps dilute urine and reduces the risk of stone formation. Eliminating all sources of calcium is not recommended as calcium is essential for various bodily functions and eliminating it can lead to other health issues. Aspirin and aspirin-containing products do not directly cause kidney stones. Antibiotics are not used to prevent or treat renal calculi, as they are not caused by bacterial infections.