Nokea
The nurse is caring for a client who has just undergone a nephrectomy. Which of the following interventions is most important in the immediate postoperative period?
- A. Monitor urine output.
- B. Encourage early ambulation.
- C. Administer oral fluids immediately.
- D. Keep the client on bed rest for 48 hours.
Correct Answer: A
Rationale: Monitoring urine output is critical post-nephrectomy to assess the function of the remaining kidney.
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The nurse is preparing to care for a client who has undergone esophagogastroduodenoscopy (EGD). After checking the vital signs, what should be the nurse's next priority?
- A. Monitor for sharp epigastric pain.
- B. Give warm gargles for sore throat.
- C. Check for a return of the gag reflex.
- D. Monitor for complaints of heartburn.
Correct Answer: C
Rationale: The nurse places highest priority on assessing for the return of the gag reflex, which is part of maintaining the client's airway. The nurse should also monitor the client for sharp pain (may indicate a potential complication) and heartburn. The client would receive warm gargles, but this cannot be done until the gag reflex has returned.
A client with a diagnosis of Parkinson's disease is prescribed pramipexole (Mirapex). The nurse should monitor the client for which of the following side effects?
- A. Hypertension.
- B. Drowsiness.
- C. Weight gain.
- D. Hyperglycemia.
Correct Answer: B
Rationale: Pramipexole, a dopamine agonist, commonly causes drowsiness, which the nurse should monitor in Parkinson's clients.
Which is an intrinsic risk factor that places the client at risk for pressure ulcers?
- A. Pressure
- B. Shearing
- C. Impaired tissue perfusion
- D. Friction
Correct Answer: C
Rationale: Impaired tissue perfusion is an intrinsic risk factor for pressure ulcers, as it reduces oxygen and nutrient delivery to tissues, increasing susceptibility to breakdown.
The nurse is caring for a client with a history of peripheral arterial disease. Which of the following interventions should be included in the plan of care?
- A. Elevate the legs above heart level.
- B. Apply heating pads to the affected limbs.
- C. Encourage walking to tolerance.
- D. Restrict fluid intake.
Correct Answer: C
Rationale: Walking to tolerance improves collateral circulation in peripheral arterial disease.
The nurse is teaching a client with a new diagnosis of asthma about self-management. Which of the following instructions should be included?
- A. Use a peak flow meter daily.
- B. Avoid exercise to prevent attacks.
- C. Take bronchodilators daily.
- D. Limit fluid intake.
Correct Answer: A
Rationale: Daily peak flow meter use monitors lung function and guides asthma management.