Nokea
An hour after administering 60 mg of furosemide intravenously (IV), which assessments should the nurse perform to determine the patient's response to treatment?
- A. Urinary output.
- B. Skin elasticity.
- C. Pain scale.
- D. Lung sounds.
- E. Oxygen saturation.
Correct Answer: A,D,E
Rationale: Assessing urinary output, lung sounds, and oxygen saturation evaluates furosemide's effectiveness in reducing fluid overload and improving respiratory status.
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After a transurethral resection of the prostate (TURP), a patient is discharged from the hospital with an indwelling urinary catheter. What is the most important instruction for the nurse to include in the discharge teaching plan?
- A. Eliminate all spicy foods from your diet
- B. Drink 3 liters of water each day
- C. Clamp the catheter when taking a shower
- D. Avoid driving a car for 2 weeks
Correct Answer: B
Rationale: Adequate hydration (3 liters daily) prevents urinary tract infections and supports recovery after TURP.
A young adult client with osteoarthritis of both knees expresses the desire to continue daily walks in the park with friends. How should the nurse respond?
- A. Encourage continued maintenance of the walking routine.
- B. Advise less weight-bearing to prevent joint destruction.
- C. Recommend walking indoors for improved stability and safety.
- D. Suggest a calcium supplement along with continued walking.
Correct Answer: A
Rationale: Encouraging the client to continue their walking routine supports their desire to stay active and promotes muscle strength, flexibility, and overall well-being, which are beneficial for managing osteoarthritis.
A client with right hydronephrosis and a history of renal calculi is preparing for discharge following a retrograde pyelogram. Which instruction should the nurse include in the client's discharge instructions?
- A. Use an incentive spirometer.
- B. Monitor the urinary stream for decreased output.
- C. Restrict physical activities.
- D. Report when hematuria becomes pink-tinged.
Correct Answer: B
Rationale: Monitoring urinary output detects complications like obstruction in hydronephrosis or renal calculi.
A patient has arrived at the emergency department reporting intermittent fever and night sweats for the past three weeks and has developed a cough that is productive with small amounts of blood. What should be the nurse's priority intervention?
- A. Obtain a sputum sample.
- B. Arrange transport for radiographic imaging.
- C. Move the patient into airborne isolation.
- D. Collect specimens for blood cultures.
Correct Answer: C
Rationale: Symptoms suggestive of tuberculosis require immediate airborne isolation to prevent transmission.
A client receives a prescription for 1 liter of lactated Ringer's intravenously (IV) to be infused over 8 hours. The IV administration set delivers 15 gtt/mL. How many mL/hr should the nurse program the infusion pump to deliver?
- A. 100 mL/hr
- B. 125 mL/hr
- C. 150 mL/hr
- D. 175 mL/hr
Correct Answer: B
Rationale: Dividing 1000 mL by 8 hours yields 125 mL/hr, the correct infusion rate.