Nokea
Postoperatively, which assessment finding is most suggestive that the client is hemorrhaging?
- A. Acute flank pain
- B. Abdominal distention
- C. Flushed, warm skin
- D. Nausea and vomiting
Correct Answer: B
Rationale: Abdominal distention may indicate internal bleeding, a critical sign of hemorrhage post-nephrectomy.
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The client has received IV solutions for three (3) days through a 20-gauge IV catheter placed in the left cephalic vein. On morning rounds, the nurse notes the IV site is tender to palpation and a red streak has formed. Which intervention should the nurse implement first?
- A. Start a new IV in the right hand.
- B. Discontinue the intravenous line.
- C. Complete an incident record.
- D. Place a warm washrag over the site.
Correct Answer: B
Rationale: Tenderness and a red streak indicate phlebitis or infection. Discontinuing the IV line prevents further complications. Starting a new IV, completing an incident report, or applying warmth are secondary actions.
The nurse is developing a plan of care for a client diagnosed with ARF. Which statement is an appropriate outcome for the client?
- A. Monitor intake and output every shift.
- B. Decrease of pain by three (3) levels on a 1-to-10 scale.
- C. Electrolytes are within normal limits.
- D. Administer enemas to decrease hyperkalemia.
Correct Answer: C
Rationale: An appropriate outcome for ARF is achieving normal electrolyte levels, as imbalances like hyperkalemia are common. Monitoring intake/output and administering enemas are interventions, not outcomes, and pain reduction is less specific to ARF.
The client is admitted to the emergency department after a gunshot wound to the abdomen. Which nursing intervention should the nurse implement first to prevent ARF?
- A. Administer normal saline IV.
- B. Take vital signs.
- C. Place client on telemetry.
- D. Assess abdominal dressing.
Correct Answer: A
Rationale: A gunshot wound can cause hypovolemia, leading to prerenal ARF. Administering normal saline IV restores volume and perfusion, preventing ARF. Vital signs, telemetry, and dressing assessment are important but secondary to fluid resuscitation.
The client is diagnosed with an acute episode of ureteral calculi. Which client problem is priority when caring for this client?
- A. Fluid volume loss.
- B. Knowledge deficit.
- C. Impaired urinary elimination.
- D. Alteration in comfort.
Correct Answer: D
Rationale: Severe pain (alteration in comfort) is the priority in acute ureteral calculi, as it affects the client’s immediate well-being and requires prompt management. Fluid loss, urinary elimination, and knowledge are secondary.
To avoid erroneous test results caused by the manipulation of the prostate, which diagnostic test should be performed before the client's rectal examination?
- A. Kidneys, ureters, bladder X-ray
- B. Needle biopsy of the prostate gland
- C. Prostate-specific antigen (PSA) test
- D. Transrectal ultrasound examination
Correct Answer: C
Rationale: The PSA test should be done before rectal examination, as manipulation can elevate PSA levels, leading to false results.