Nokea
In addition to nausea and severe flank pain, a female client with renal calculi has pain in the groin and bladder. The nurse should assess the client further for six years of:
- A. Nephritis.
- B. Referred pain.
- C. Urine retention.
- D. Additional stone formation.
Correct Answer: B
Rationale: Groin and bladder pain in renal calculi often indicate referred pain from the stone's movement or irritation along the urinary tract.
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Which finding indicates effective hemodialysis?
- A. Decreased BUN.
- B. Increased potassium.
- C. Weight gain.
- D. Hypotension.
Correct Answer: A
Rationale: Decreased BUN indicates effective removal of waste products.
A client with a fracture develops compartment syndrome. Which of the following signs should alert the nurse to impending organ failure?
- A. A condition.
- B. Jaundice.
- C. Generalized edema.
- D. Dark, scanty urine.
Correct Answer: D
Rationale: Dark, scanty urine indicates renal failure, a potential complication of compartment syndrome due to myoglobin release.
A client is admitted to the emergency department with a headache, weakness, and slight confusion. The physician diagnoses carbon monoxide poisoning. What should the nurse do first?
- A. Initiate gastric lavage.
- B. Maintain body temperature.
- C. Administer 100% oxygen by mask.
- D. Obtain a psychiatric referral.
Correct Answer: C
Rationale: Administering 100% oxygen displaces carbon monoxide from hemoglobin, the priority in poisoning. Gastric lavage, temperature maintenance, and psychiatric referrals are secondary.
The client with Hodgkin's disease undergoes an excisional cervical lymph node biopsy under local anesthesia. After the procedure, which does the nurse assess first?
- A. Vital signs.
- B. The incision.
- C. The airway.
- D. The neurologic signs.
Correct Answer: C
Rationale: After a cervical lymph node biopsy, the nurse should first assess the airway, as swelling or hematoma in the neck could compromise breathing. Vital signs, incision, and neurologic signs are assessed next.
The client's blood urea nitrogen (BUN) concentration is elevated in acute renal failure. What is the likely cause of this finding?
- A. Fluid retention.
- B. Hemolysis of red blood cells.
- C. Below-normal metabolic rate.
- D. Reduced renal blood flow.
Correct Answer: D
Rationale: Reduced renal blood flow impairs urea excretion, causing elevated BUN levels in acute renal failure.