Nokea
The client diagnosed with ARF is experiencing hyperkalemia. Which medication should the nurse prepare to administer to help decrease the potassium level?
- A. Erythropoietin.
- B. Calcium gluconate.
- C. Regular insulin.
- D. Osmotic diuretic.
Correct Answer: C
Rationale: Regular insulin, often given with glucose, drives potassium into cells, temporarily lowering serum potassium levels in hyperkalemia. Calcium gluconate stabilizes cardiac membranes, erythropoietin treats anemia, and osmotic diuretics are not used for hyperkalemia.
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After the cystoscopy, which urinary symptom can the nurse expect the client to report?
- A. A sense of urgency
- B. No urinary output
- C. A strong urinary odor
- D. A large volume of urine output
Correct Answer: A
Rationale: A sense of urgency is common after cystoscopy due to urethral irritation from the procedure.
The nurse is caring for a pregnant client diagnosed with acute pyelonephritis. Which scientific rationale supports the client being hospitalized for this condition?
- A. The client must be treated aggressively to prevent maternal/fetal complications.
- B. The nurse can force the client to drink fluids and avoid nausea and vomiting.
- C. The client will be dehydrated and there won’t be sufficient blood flow to the baby.
- D. Pregnant clients historically are afraid to take the antibiotics as ordered.
Correct Answer: A
Rationale: Acute pyelonephritis in pregnancy risks maternal sepsis and fetal complications (e.g., preterm labor). Hospitalization ensures aggressive IV antibiotic treatment and monitoring. Dehydration and antibiotic fears are secondary concerns.
The nurse is teaching the female client diagnosed with tuberculosis of the urinary tract prior to discharge. Which information should the nurse include specific to this diagnosis?
- A. Instruct the client to take the medication with food.
- B. Explain condoms should be used during treatment.
- C. Discuss the need for follow-up chest x-rays.
- D. Encourage a well-balanced diet and fluid intake.
Correct Answer: B
Rationale: Urinary TB can spread to sexual partners, so condoms are recommended during treatment. Medication timing, chest x-rays (for pulmonary TB), and diet/fluids are general or less specific.
The nurse is caring for a client with a TURP. Which expected outcome indicates the client’s condition is improving?
- A. The client is using the maximum amount allowed by the PCA pump.
- B. The client’s bladder spasms are relieved by medication.
- C. The client’s scrotum is swollen and tender with movement.
- D. The client has passed a large, hard, brown stool this morning.
Correct Answer: B
Rationale: Relief of bladder spasms indicates reduced irritation and healing post-TURP. Maximum PCA use, scrotal swelling, or hard stools do not reflect improvement and may indicate complications.
Which assessment supports the nurse's assumption that the client's sleep disturbance was most likely due to anxiety?
- A. The client was pacing the room before bedtime.
- B. The client's vital signs were stable during the night.
- C. The client requested a sleeping pill earlier.
- D. The client reported feeling rested in the morning.
Correct Answer: A
Rationale: Pacing before bedtime is a behavioral sign of anxiety, supporting the assumption that anxiety caused the sleep disturbance.