Nokea
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.
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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.
The telemetry monitor technician notifies the nurse of the morning telemetry readings. Which client should the nurse assess first?
- A. The client in normal sinus rhythm with a peaked T wave.
- B. The client diagnosed with atrial fibrillation with a rate of 100.
- C. The client diagnosed with a myocardial infarction who has occasional PVCs.
- D. The client with a first-degree atrioventricular block and a rate of 92.
Correct Answer: A
Rationale: Peaked T waves indicate hyperkalemia, which can lead to life-threatening arrhythmias, requiring immediate assessment. Atrial fibrillation, PVCs, and first-degree AV block are less urgent unless unstable.
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.
As the nurse instructs the client about CBI, which information should the nurse provide? Select all that apply.
- A. You may feel the urge to urinate even though the bladder is empty.
- B. Do not to try to urinate around the catheter, because this will cause bladder spasms.
- C. You need to limit your fluids to 4 glasses per day.
- D. It is normal for the urine to be bloody immediately after surgery.
- E. The catheter will be removed in about a week.
- F. By the time you are ready to go home, your urine should be pink with a few clots.
Correct Answer: A,B,D,F
Rationale: These statements accurately describe CBI effects, expectations, and precautions post-TURP.
Which nursing intervention promotes the spontaneous passage of ureteral stones?
- A. Encouraging ambulation as tolerated
- B. Restricting fluid intake
- C. Administering diuretics
- D. Keeping the client on bed rest
Correct Answer: A
Rationale: Encouraging ambulation promotes gravity-assisted stone movement through the ureter, facilitating spontaneous passage.