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The nurse has an order to administer 2 oz of lactulose (Cephulac) to a client who has cirrhosis. How many milliliters of lactulose should the nurse administer?
Correct Answer: 60 mL
Rationale: 2 oz equals 60 mL (1 oz = 30 mL), so the nurse should administer 60 mL of lactulose (A).
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A client with renal calculi has hematuria. The nurse should:
- A. Monitor urine output.
- B. Notify the physician immediately.
- C. Restrict fluids.
- D. Apply ice to the flank.
Correct Answer: A
Rationale: Hematuria is expected with renal calculi; monitoring ensures no excessive bleeding.
A nurse is planning care for a client who underwent a percutaneous needle biopsy of the kidney. What should the nurse plan to do immediately after the biopsy? Select all that apply.
- A. Assess the biopsy site.
- B. Take vital signs every hour.
- C. Assess urine for hematuria.
- D. Place the client in a prone position.
- E. Assess the client for chest pain.
Correct Answer: A,C,D
Rationale: Assessing the biopsy site, urine for hematuria, and placing the client prone help monitor for bleeding and promote hemostasis post-biopsy.
The nurse is monitoring a client post-insertion of a nasogastric tube for an intestinal obstruction. Which finding indicates the tube is functioning correctly?
- A. Clear, watery output.
- B. Bright red blood in the drainage.
- C. No output for 12 hours.
- D. Thick, mucus-like drainage.
Correct Answer: A
Rationale: Clear, watery output from a nasogastric tube indicates it is effectively decompressing the intestine by removing fluid and gas. Bright red blood suggests bleeding, no output may indicate a blockage, and thick drainage is not typical. CN: Physiological adaptation; CL: Evaluate
The nurse is planning care for a client with severe postoperative pain. There is an order for 10 mg MSO4. Which of the following should the nurse do first?
- A. Obtain an intravenous infusion system.
- B. Prepare the medication for administration.
- C. Contact the Pharmacy Department.
- D. Contact the physician that ordered the medication.
Correct Answer: A
Rationale: MSO4 (morphine sulfate) is typically given IV for severe pain. Obtaining an IV infusion system ensures the medication can be administered safely and effectively.
A client with colon cancer undergoes surgical removal of a segment of colon and creation of a sigmoid colostomy. What assessments by the nurse indicate the client is developing complications within the first 24 hours? Select all that apply.
- A. Coarse breath sounds auscultated bilaterally at the bases.
- B. Dusky appearance of the stoma.
- C. No drainage in the ostomy appliance.
- D. Temperature greater than 101.2°F (38.5°C).
- E. Decreased bowel sounds.
Correct Answer: B,C,D
Rationale: A dusky stoma (B) indicates poor blood supply, no drainage (C) suggests obstruction or dysfunction, and fever (D) may indicate infection, all of which are complications post-colostomy. Coarse breath sounds (A) and decreased bowel sounds (E) are not necessarily indicative of immediate complications.