Nokea
Post-cystectomy, a client asks about the purpose of the ileal conduit. The nurse explains it is to:
- A. Store urine in the bladder.
- B. Divert urine to an external pouch.
- C. Filter blood in the kidneys.
- D. Reabsorb water in the intestines.
Correct Answer: B
Rationale: An ileal conduit diverts urine from the ureters to a stoma, collected in an external pouch.
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The client asks the nurse what his activity limitations are while he is in Buck's traction. The nurse should tell the client:
- A. You can sit up whenever you want.'
- B. You must lie flat on your back most of the time.'
- C. You can turn your body.'
- D. You must lie on your stomach.'
Correct Answer: B
Rationale: Buck's traction requires lying flat to maintain traction alignment, limiting movement.
The nurse teaches a client about heat and cold treatments to manage arthritis pain. Which of the following client statements indicates that the client still has a knowledge deficit?
- A. I can use heat and cold as often as I want.'
- B. With heat, I should apply it for no longer than 20 minutes at a time.'
- C. Heat-producing liniments can be used with other heat devices.'
- D. Ten to 15 minutes per application is the maximum time for cold applications.'
Correct Answer: A
Rationale: Frequent or prolonged use of heat and cold without guidance can cause tissue damage. The other statements reflect appropriate understanding of time limits and safe use.
A client informs the nurse that she is using an herbal therapy while receiving chemotherapy. Which of the following actions should the nurse take?
- A. Determine what substances the client is using and make sure that the physician is aware of all therapies the client is using.
- B. Guide the client in the decision-making process to select either Western or alternative medicine.
- C. Encourage the client to seek alternative modalities that do not require the ingestion of substances.
- D. Recommend that the client stop using the alternative medicines immediately.
Correct Answer: A
Rationale: Determining the herbal therapies used and informing the physician ensures safety, as some herbs can interact with chemotherapy drugs, affecting efficacy or toxicity.
After pituitary surgery, the nurse should assess the client for which of the following?
- A. Urine specific gravity less than 1.010.
- B. Urine output between 1 and 2 L/day.
- C. Blood glucose level higher than 300 mg/dL.
- D. Urine negative for glucose and ketones.
Correct Answer: A
Rationale: Low urine specific gravity (<1.010) may indicate diabetes insipidus, a common complication post-pituitary surgery due to reduced vasopressin.
A client with Raynaud's phenomenon is prescribed diltiazem (Cardizem). An expected outcome is:
- A. Decreased heart rate
- B. A return to normal sinus rhythm
- C. Reduced episodes of finger numbness
- D. Increased SpO2
Correct Answer: C
Rationale: Diltiazem, a calcium channel blocker, reduces vasospasm in Raynaud's by promoting vasodilation, decreasing episodes of finger numbness. It may lower heart rate or affect rhythm, but these are not primary goals, and SpO2 is not directly improved.