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The nurse is caring for a client diagnosed with psoriasis vulgaris who is receiving a psoralen and ultraviolet A light (PUVA) treatment. Which assessment finding indicates that the client has been overexposed to the treatment?
- A. Brown, rough, greasy, wart-like papules on the face.
- B. Thick skin plaques topped by silvery white scales.
- C. Requires sunglasses because sunlight hurts eyes.
- D. Tenderness upon palpation and generalized erythema.
Correct Answer: D
Rationale: Tenderness and generalized erythema indicate overexposure to PUVA, signaling potential burns or excessive UV exposure.
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After a transurethral resection of the prostate (TURP), a patient is discharged from the hospital with an indwelling urinary catheter. What is the most important instruction for the nurse to include in the discharge teaching plan?
- A. Eliminate all spicy foods from your diet
- B. Drink 3 liters of water each day
- C. Clamp the catheter when taking a shower
- D. Avoid driving a car for 2 weeks
Correct Answer: B
Rationale: Adequate hydration (3 liters daily) prevents urinary tract infections and supports recovery after TURP.
A client with right hydronephrosis and a history of renal calculi is preparing for discharge following a retrograde pyelogram. Which instruction should the nurse include in the client's discharge instructions?
- A. Use an incentive spirometer.
- B. Monitor the urinary stream for decreased output.
- C. Restrict physical activities.
- D. Report when hematuria becomes pink-tinged.
Correct Answer: B
Rationale: Monitoring urinary output detects complications like obstruction in hydronephrosis or renal calculi.
A client with multiple sclerosis has urinary retention related to sensorimotor deficits. Which action should the nurse include in the client's plan of care?
- A. Explain the need to limit intake of oral fluids to reduce client discomfort.
- B. Teach the client techniques for performing intermittent catheterization.
- C. Remind the client to practice pelvic floor (Kegel) exercises regularly.
- D. Provide a bedside commode for immediate use in the client's room.
Correct Answer: B
Rationale: Intermittent catheterization manages urinary retention effectively in multiple sclerosis, maintaining bladder health.
The nurse is caring for a patient with chronic pancreatitis who reports persistent gnawing abdominal pain. What assessment data is most important for the nurse to obtain to help manage the patient's pain?
- A. Activity level of bowel sounds.
- B. Level and amount of physical activity.
- C. Eating patterns of dietary intake.
- D. Color and consistency of feces.
Correct Answer: C
Rationale: Eating patterns identify foods that exacerbate pancreatitis pain, guiding dietary modifications.
A client receives a prescription for 1 liter of lactated Ringer's intravenously (IV) to be infused over 8 hours. The IV administration set delivers 15 gtt/mL. How many mL/hr should the nurse program the infusion pump to deliver?
- A. 100 mL/hr
- B. 125 mL/hr
- C. 150 mL/hr
- D. 175 mL/hr
Correct Answer: B
Rationale: Dividing 1000 mL by 8 hours yields 125 mL/hr, the correct infusion rate.