Nokea
The nurse has been asked to prepare an intervention plan for a client, age 70, admitted for treatment of renal calculi. He complains of frequent pain due to increased pressure in the renal pelvis and is frightened of the excruciating pain. Which of the ff measures can the nurse include in the client's nursing care plan? Choose all that apply
- A. Administer prescribed nephrotoxic drugs
- B. Encourage ambulation and liberal fluid
- C. Observe aseptic principles when changing intake
- D. Provide a comfortable position
Correct Answer: B
Rationale: A. Administer prescribed nephrotoxic drugs - This measure is not appropriate for the client's care plan as nephrotoxic drugs can further harm the kidneys, exacerbating the condition of renal calculi.
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A client is receiving chemotherapy to treat breath cancer. Which assessment finding indicates a fluid and electrolyte imbalance induced by chemotherapy?
- A. A Urine output of 400 ml in 8 hours
- B. B. Serum potassium level of 3.6 mEq/L
- C. C. Blood pressure of 120/64 to 130/72 mm Hg
- D. D. Dry oral mucous membranes and cracked lips
Correct Answer: A
Rationale: Chemotherapy can cause fluid and electrolyte imbalances in the body, leading to potential kidney damage and altered urinary output. A low urine output of 400 ml in 8 hours could indicate dehydration or impaired renal function, both of which can be induced by chemotherapy. Monitoring urine output is crucial in assessing the patient's fluid balance and kidney function during chemotherapy. It is essential to identify and address such imbalances promptly to prevent complications.
A preterm newborn requires oxygen and mechanical ventilation. Which complications should the nurse assess for?
- A. Bronchopulmonary dysplasia, pneumothorax
- B. Anemia, necrotizing enterocolitis
- C. Cerebral palsy, persistent patent ductus
- D. Congestive heart failure, cerebral edema
Correct Answer: A
Rationale: Preterm newborns who require oxygen and mechanical ventilation are at risk for developing bronchopulmonary dysplasia (BPD) and pneumothorax. BPD is a chronic lung disease that can occur in premature infants who have been on mechanical ventilation and supplemental oxygen. Pneumothorax is another common complication in preterm newborns due to the fragility of their lungs. Therefore, the nurse should closely monitor for signs and symptoms of these complications in a preterm newborn requiring oxygen and mechanical ventilation.
Which of the following signs indicates to the nurse that digoxin (Lanoxin) has been effective for a patient?
- A. Urine output decreases
- B. Heart rate higher than 95
- C. Urine output increases
- D. Heart rate lower than 50
Correct Answer: C
Rationale: Digoxin is a medication commonly used to treat heart failure and certain types of irregular heart rhythms. One of the therapeutic effects of digoxin is an improvement in cardiac output, leading to better tissue perfusion. As the heart's pumping ability improves, blood flow to the kidneys also increases, resulting in an increase in urine output. Therefore, an increase in urine output is a positive indication that digoxin is effective for the patient. Monitoring urine output can be a valuable way for nurses to assess the response to digoxin therapy and the overall cardiac function of the patient.
A patient is admitted for a splenectomy. Why is an injection of Vit. K ordered before surgery?
- A. To correct clotting problems
- B. To prevent postoperative infection
- C. To promote healing
- D. To dry secretions
Correct Answer: A
Rationale: Vitamin K plays a crucial role in the production of clotting factors in the liver. Patients undergoing a splenectomy may be at an increased risk of bleeding during and after surgery due to the decreased availability of these clotting factors. Administering Vitamin K before the surgery helps to correct any potential clotting problems, ensuring proper hemostasis and reducing the risk of excessive bleeding during the procedure. This preoperative intervention can help optimize the patient's coagulation status and improve their outcomes postoperatively.
You are evaluating a 6-year-old male child with Langerhans cell histiocytosis (LCH); the parents state that the most common site of bone involvement is
- A. skull
- B. vertebra
- C. mandible
- D. pelvis
Correct Answer: A
Rationale: Skull is the most common site of bone involvement in LCH.