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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: The correct answer is B: Encourage ambulation and liberal fluid. Encouraging ambulation can help in the movement of kidney stones and alleviate pain. Liberal fluid intake helps in flushing out kidney stones and preventing further stone formation.
Incorrect options:
A: Administering prescribed nephrotoxic drugs can worsen kidney function and exacerbate the pain.
C: Observing aseptic principles when changing intake is important for infection prevention but not directly related to pain management for renal calculi.
D: Providing a comfortable position can offer temporary relief but does not address the underlying cause of kidney stone pain.
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A client is admitted for treatment of the syndrome of inappropriate antidiuretic hormone (SIADH). Which nursing intervention is appropriate?
- A. Infusing IV fluids rapidly as ordered
- B. Administering glucose-containing IV
- C. Encouraging increased oral intake fluids as ordered
- D. Restricting fluids
Correct Answer: D
Rationale: The correct answer is D: Restricting fluids. In SIADH, there is an excess of antidiuretic hormone leading to water retention and dilutional hyponatremia. Restricting fluids helps to prevent further water retention and hyponatremia. Rapid IV fluid infusion (A) worsens the condition by further diluting sodium levels. Administering glucose-containing IV (B) is not directly related to treating SIADH. Encouraging increased oral intake (C) can exacerbate the condition by increasing fluid intake.
The physician orders propranolol (Inderal) for a client's angina. The effect of this drug is to:
- A. Act as a vasoconstrictor
- B. Block beta stimulation in the heart
- C. Act as a vasodilator
- D. Increase the heart rate
Correct Answer: B
Rationale: The correct answer is B: Block beta stimulation in the heart. Propranolol is a beta-blocker that works by blocking the beta receptors in the heart, which reduces the heart's workload and oxygen demand, making it an effective treatment for angina. By blocking beta stimulation, propranolol helps to decrease heart rate, blood pressure, and myocardial contractility. This ultimately improves oxygen supply to the heart muscle.
Explanation for other choices:
A: Act as a vasoconstrictor - Propranolol does not act as a vasoconstrictor; it actually can cause vasodilation in some cases.
C: Act as a vasodilator - Propranolol is not primarily a vasodilator; its main action is to block beta stimulation in the heart.
D: Increase the heart rate - Propranolol actually decreases heart rate by blocking beta receptors in the heart.
Following a unilateral adrenalectomy, the nurse would assess for hyperkalemia shown by which of the following?
- A. Muscle weakness
- B. Diaphoresis
- C. Tremors
- D. Constipation
Correct Answer: A
Rationale: The correct answer is A: Muscle weakness. After unilateral adrenalectomy, there is a risk of hyperkalemia due to decreased aldosterone production. Aldosterone helps regulate potassium levels in the body. Muscle weakness is a common symptom of hyperkalemia as high potassium levels can affect muscle function. Diaphoresis, tremors, and constipation are not typically associated with hyperkalemia. Diaphoresis is excessive sweating, tremors are involuntary muscle movements, and constipation is difficulty passing stool. These symptoms are not directly related to potassium imbalance.
A client who underwent litholapaxy surgery for removing bladder stones wants to know how long the urethral catheter needs to stay in place. Which of the ff is the correct response?
- A. The catheter should remain in place for 7 days
- B. The catheter should remain in place for 1-2 days
- C. The catheter should remain in place for 2-3 days
- D. The catheter should remain in place for 3-4 days
Correct Answer: B
Rationale: The correct answer is B: The catheter should remain in place for 1-2 days. After litholapaxy surgery, the urethral catheter is typically removed within 1-2 days to prevent infection and promote healing. Keeping the catheter in place for too long can increase the risk of complications such as urinary tract infections. Options A, C, and D suggest longer durations which are not necessary and may lead to unnecessary discomfort and risks for the client. Therefore, the optimal timeframe for catheter removal post-litholapaxy surgery is within 1-2 days.
A client receives a sealed radiation implant to treat cervical cancer. When caring for this client, the nurse should:
- A. Consider the client’s urine, feces, and vomitus to be highly radioactive
- B. Consider the client to be radioactive for 10 days after implant removal
- C. Allow soiled linens to remain in the room until after the client is discharged
- D. Maintain the client on complete bed rest with bathroom privileges only
Correct Answer: B
Rationale: The correct answer is B because the client remains radioactive for a period of time after the implant removal, typically around 10 days. During this time, the nurse should take precautions to limit exposure to radiation. Choice A is incorrect because bodily fluids are not highly radioactive, and proper disposal procedures should be followed. Choice C is incorrect as soiled linens should be handled appropriately to prevent contamination. Choice D is incorrect as bed rest may not be necessary, and mobility should be encouraged within safety guidelines.