Nokea
The nurse instructs the unlicensed assistive personnel on how to collect a 24-hour urine specimen. Which of the following instructions is correct for a collection that is scheduled to start at 7 a.m. Monday and end at 7 a.m. Tuesday?
- A. Collect and save the urine voided at 7 a.m. on Monday.
- B. Send the first voided urine specimen on Monday to the laboratory for culture.
- C. Collect and save the urine voided at 7 a.m. on Tuesday.
- D. Keep each day's urine collection in separate containers.
Correct Answer: C
Rationale: The 24-hour collection includes all urine from after the 7 a.m. Monday void (discarded) to the 7 a.m. Tuesday void (included).
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A client with a history of rheumatoid arthritis is prescribed etanercept (Enbrel). The nurse should monitor the client for which of the following adverse effects?
- A. Increased infection risk.
- B. Hyperglycemia.
- C. Hypertension.
- D. Weight loss.
Correct Answer: A
Rationale: Etanercept, a biologic, increases infection risk due to immunosuppression.
The nurse is planning preoperative teaching with a client scheduled for a transurethral resection of the prostate (TURP). Which most frequent cause of postoperative pain should the nurse plan to include in the discussion?
- A. Bladder spasms
- B. Bleeding within the bladder
- C. Tension on the Foley catheter
- D. The lower abdominal incision
Correct Answer: A
Rationale: Bladder spasms can occur after this surgery because of postoperative bladder distention or irritation from the balloon on the indwelling urinary catheter. The nurse administers antispasmodic medications as prescribed to treat this type of pain. Options 2 and 3 are not frequent causes of pain. Some surgeons purposefully apply tension to the catheter for a few hours postoperatively to control bleeding. There is no incision with a TURP.
The nurse should assess the child with nephrotic syndrome for which of the following? Select all that apply.
- A. Normal blood pressure.
- B. Generalized edema.
- C. Normal serum lipid levels.
- D. No red blood cells in the urine.
- E. Elevated streptococcal antibody titers.
Correct Answer: B,D
Rationale: Nephrotic syndrome is characterized by generalized edema and no red blood cells in the urine. Blood pressure may be elevated, serum lipids are typically high, and streptococcal antibodies are not typically associated.
A client with a spinal cord injury is at risk for autonomic dysreflexia. Which symptom should the nurse monitor for?
- A. Bradycardia.
- B. Hypotension.
- C. Severe headache.
- D. Increased urine output.
Correct Answer: C
Rationale: Severe headache is a key sign of autonomic dysreflexia, often triggered by bladder or bowel issues.
The nurse is teaching a client with gout about dietary management. Which of the following foods should the client avoid?
- A. Spinach.
- B. Cherries.
- C. Organ meats.
- D. Whole grains.
Correct Answer: C
Rationale: Organ meats are high in purines, which increase uric acid levels and should be avoided in gout.