Nokea
During morning assessments, the nurse finds that a client's nephrostomy tube has been clamped. The nurse's first action should be to:
- A. Assess the drainage bag.
- B. Check for bladder distention.
- C. Unclamp the tubing.
- D. Irrigate the tubing.
Correct Answer: C
Rationale: Unclamping the nephrostomy tube is the priority to restore urine flow and prevent complications like hydronephrosis or infection.
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The nurse is caring for a client who is receiving magnesium sulfate for preeclampsia. Which intervention is most appropriate to prevent toxicity?
- A. Monitor respiratory rate
- B. Assess deep tendon reflexes
- C. Measure urine output
- D. All of the above
Correct Answer: D
Rationale: Magnesium sulfate toxicity can cause respiratory depression loss of reflexes and reduced urine output. Monitoring respiratory rate reflexes and urine output is essential to detect toxicity early and ensure patient safety.
Discharge teaching for the client who has a total gastrectomy should include which of the following?
- A. Need for the client to increase fluid intake to 3000 mL/day
- B. Follow-up visits every 3 weeks for the first 6 months
- C. B12 injections needed for the rest of the client's life
- D. Need to eat three full meals with plenty of fiber per day
Correct Answer: C
Rationale: There will be no need to increase fluid intake excessively, because dumping syndrome could present a problem. Follow-up visits every 3 weeks are not a standard recommendation. Follow-up visits will be highly individualized. With removal of the stomach, intrinsic factor will no longer be produced. Intrinsic factor is necessary for vitamin B12 absorption. Parenteral injections of B12 will be needed on a monthly basis for the rest of the person's life. Smaller, more frequent meals, rather than large, bulky meals, are recommended to prevent problems with dumping syndrome.
A 14-year-old client has a history of lying, stealing, and destruction of property. Personal items of peers have been found missing. After group therapy, a peer approaches the nurse to report that he has seen the 14-year-old with some of the missing items. The best response of the nurse is to:
- A. Request that he explain to the group why he took personal items from peers
- B. Approach him when he is alone to inquire about his involvement in the incident
- C. Imply to him that you doubt his involvement in the incident and request his denial
- D. Confront him openly in group and request an apology
Correct Answer: B
Rationale: This answer is incorrect. There is no proof that he removed the missing items. This answer is correct. Anxiety and defensiveness are lessened if the individual is approached in this manner. This answer is incorrect. It is difficult for one to admit to wrongdoing with this approach. This answer is incorrect. He has not yet been proved guilty. Confrontation will only increase defensiveness and anxiety.
A client with a history of a peptic ulcer is being discharged. The nurse should teach the client to:
- A. Avoid spicy foods
- B. Eat large meals
- C. Lie down after eating
- D. Increase caffeine intake
Correct Answer: A
Rationale: Spicy foods can irritate a peptic ulcer, delaying healing. Small meals, avoiding lying down post-meals, and limiting caffeine are also recommended.
The nurse teaches a male client ways to reduce the risks associated with furosemide therapy. Which of the following indicates that he understands this teaching?
- A. I'll be sure to rise slowly and sit for a few minutes after lying down.'
- B. I'll be sure to walk at least 2-3 blocks every day.'
- C. I'll be sure to restrict my fluid intake to four or five glasses a day.'
- D. I'll be sure not to take any more aspirin while I am on this drug.'
Correct Answer: A
Rationale: Rising slowly prevents postural hypotension, a common side effect of furosemide that increases fall risk. The other options are not specific to furosemide therapy risks.