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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The nurse is planning care for a client with osteomyelitis. The client is taking an antibiotic, but the infection has not resolved. The nurse should advise the client to do which of the following?
- A. Use herbal supplements.
- B. Eat a diet high in protein and vitamins C and D.
- C. Ask the health care provider for a change of antibiotics.
- D. Encourage frequent passive range-of-motion to the affected extremity.
Correct Answer: B
Rationale: A diet high in protein and vitamins C and D supports tissue healing and immune function in osteomyelitis.
A client's chest tube is to be removed by the physician. Which of the following items should the nurse have ready to be placed directly over the wound when the chest tube is removed?
- A. Butterfly dressing.
- B. Montgomery strap.
- C. Fine-mesh gauze dressing.
- D. Petroleum gauze dressing.
Correct Answer: D
Rationale: Petroleum gauze creates an airtight seal over the chest tube site, preventing air entry into the pleural space. Other dressings are less occlusive.
Which of the following is the most common initial manifestation of acute renal failure?
- A. Dysuria.
- B. Anuria.
- C. Hematuria.
- D. Oliguria.
Correct Answer: D
Rationale: Oliguria, reduced urine output, is the most common initial sign of acute renal failure due to impaired kidney filtration.
The nurse is unable to palpate the client's left pedal pulses. Which of the following actions should the nurse take next?
- A. Auscultate the pulses with a stethoscope
- B. Call the physician
- C. Use a Doppler ultrasound device
- D. Inspect the lower left extremity
Correct Answer: C
Rationale: If pedal pulses are not palpable, the next step is to use a Doppler ultrasound device to detect blood flow, as pulses may be weak due to PVD or other causes. Auscultation is not used for peripheral pulses, calling the physician is premature, and inspection is less specific than Doppler assessment.
Which of the following skin preparations would be best to apply around the client's colostomy?
- A. Karaya.
- B. Petroleum jelly.
- C. Antiseptic cream.
- D. None of the above
Correct Answer: A
Rationale: Karaya is a natural skin barrier that protects the skin around the stoma from irritation and is commonly used in ostomy care. Petroleum jelly is not suitable as it can interfere with adhesion of the ostomy appliance, and antiseptic cream is not typically used for routine skin protection around a stoma. CN: Physiological adaptation; CL: Apply