Nokea
The nurse is caring for a client who has just returned from an intravenous urography procedure. Which intervention should the nurse take to prevent post-procedure acute kidney injury?
- A. Assess the venipuncture site for redness
- B. Have the client obtain their daily weight for three days after the procedure
- C. Instruct the client to remain motionless
- D. Encourage the client to increase their fluid intake
Correct Answer: D
Rationale: Increased fluid intake helps flush contrast media, reducing the risk of AKI post-urography.
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The nurse is teaching a client about the newly prescribed medication, sevelamer. Which statement, if made by the client, would indicate a correct understanding of the teaching?
- A. My blood pressure may increase while I take this medication.
- B. This medication will help lower my calcium level.
- C. I should take this medication with my meal.
- D. I may experience bad diarrhea with this medication.
Correct Answer: C
Rationale: Sevelamer is taken with meals to bind dietary phosphate, reducing serum phosphorus. It does not affect blood pressure (D), lower calcium (A), or typically cause diarrhea (B).
Following surgery for a prolapsed bladder, a 74-year-old female client is two days postoperative with an indwelling urinary catheter. While the nurse is making morning rounds, the client states, 'I feel like peeing again!' The most appropriate response for the nurse is:
- A. It's just bladder spasms. Nothing to worry about.'
- B. Let me look at your urine bag to ensure it's draining properly.'
- C. You should do Kegel exercises regularly to stop this urge to void.'
- D. Is this the first time this has happened?'
Correct Answer: B
Rationale: Checking the urine bag ensures the catheter is draining properly, addressing the sensation of needing to urinate.
The nurse is assessing a client who was admitted four hours ago with hypomagnesemia. Which of the following findings should the nurse recognize as a common cause of hypomagnesemia? Select all that apply.
- A. Renal failure
- B. Alcoholism
- C. Anorexia nervosa
- D. Diarrhea
- E. Hypothyroidism
Correct Answer: B,C,D
Rationale: Alcoholism, anorexia nervosa, and diarrhea cause magnesium loss through malnutrition, malabsorption, or gastrointestinal losses.
The following scenario applies to the next 1 items
The nurse in the medical-surgical unit is caring for a client.
Item 1 of 1
Progress Notes
Day 1
1700: Admitted from the emergency department with a small bowel obstruction. Nasogastric tube (NGT) was inserted with intermittent suction. Awaiting surgical consult.
Day 2
0900: Morning labs reviewed and orders were given. Still awaiting surgical consult.
Orders
Day 1:
• Insert nasogastric tube to low intermittent suction
• Insert a peripheral vascular access device
• nothing by mouth (n.p.o.) status
• consult surgery for evaluation
• continuous infusion of 0.9% sodium chloride (normal saline) 100 mL/hr
Day 2:
• potassium chloride 40 mEq via intravenous piggy-back x 1 dose
The nurse reviews the clinical data. The nurse prepares to implement the orders from day 2. Complete the following sentences by choosing from the list of options. Prior to the nurse administering the prescribed IV potassium, the nurse should....... The nurse should also.......... The nurse should infuse the IV potassium over. During the infusion, if the client should report pain at the vascular access device, the nurse should......
- A. ensure the client has adequate urine output.
- B. implement seizure precautions.
- C. initiate continuous cardiac monitoring
- D. 2 hours.
- E. 4 hours.
- F. stop the infusion.
- G. apply a warm compress to the vascular access device.
Correct Answer: A,C,E,F
Rationale: Adequate urine output and cardiac monitoring are essential before and during IV potassium infusion to prevent hyperkalemia. Infuse over 4 hours and stop if pain occurs to avoid complications.
The nurse is caring for a client in the medical-surgical unit. The nurse is reviewing the client's laboratory data and should take which action.
- A. Review the client's current medications
- B. Plan to initiate daily fluid restrictions
- C. Clarify the prescribed chest radiograph (x-ray)
- D. Insert an indwelling urinary catheter to monitor urinary output
Correct Answer: A
Rationale: Reviewing medications identifies potential causes of lab abnormalities, guiding appropriate interventions.