Nokea
The nurse is caring for a client with a history of benign prostatic hypertrophy who is prescribed finasteride (Proscar). The nurse should instruct the client that this medication works by:
- A. Relaxing bladder muscles.
- B. Reducing prostate size.
- C. Increasing urine flow.
- D. Preventing urinary infections.
Correct Answer: B
Rationale: Finasteride reduces prostate size by inhibiting testosterone conversion, relieving urinary obstruction in BPH.
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A client with a diagnosis of chronic kidney disease is prescribed a low-phosphorus diet. Which of the following foods should the nurse instruct the client to avoid?
- A. White bread.
- B. Chicken.
- C. Milk.
- D. Apples.
Correct Answer: C
Rationale: Milk is high in phosphorus and should be avoided in a low-phosphorus diet for chronic kidney disease.
A 24-year-old client has been diagnosed with acute osteomyelitis in the left leg. He complains of acute pain in the leg that intensifies when he moves it. The client has a temperature of 101°F (38.3°C) and a reddened, warm area in the midcalf region over the shaft of the tibia. Based on this information, which of the following nursing diagnoses would be most appropriate for this client?
- A. Grieving related to possible left lower leg amputation.
- B. Activity intolerance related to severe left leg pain.
- C. A disturbed body image related to left leg swelling and inflammation.
- D. Deficient fluid volume related to elevated temperature of 101°F (38.3°C).
Correct Answer: B
Rationale: Activity intolerance due to severe pain is the most appropriate diagnosis, as pain limits mobility. Amputation is not indicated, body image is secondary, and fever does not directly cause fluid volume deficit.
You are serving as the preceptor for a newly graduated nurse. As you observe the new nurse for their application of body mechanics principles into client care, you observe that the nurse spreads her legs apart during a transfer with a client. What should you do?
- A. Advise the nurse that the legs must be close together for stability during lifting and transfers.
- B. Advise the nurse that the legs should be one in front of the other and not spread apart during a transfer.
- C. Validate the nurse's competency in terms of the application of body mechanics principles during a transfer.
- D. Validate the nurse's competency in terms of the application of ergonomics principles during a transfer.
Correct Answer: C
Rationale: Spreading the legs apart during a transfer provides a wide base of support, which is a correct body mechanics principle , ensuring stability and reducing injury risk.
The nurse administers an intradermal injection to a client. Proper technique has been used if the injection site demonstrates which of the following?
- A. No swelling.
- B. Tissue pallor.
- C. Evidence of a bleb.
- D. Erythema.
Correct Answer: C
Rationale: A bleb (small wheal) at the injection site indicates correct intradermal technique, as the medication is deposited just under the skin.
The nurse is assessing a client with a suspected tension pneumothorax. Which of the following findings is most indicative of this condition?
- A. Symmetrical chest movement.
- B. Tracheal deviation to the affected side.
- C. Dull percussion note on the affected side.
- D. Absent breath sounds on the affected side.
Correct Answer: B,D
Rationale: Tracheal deviation to the unaffected side and absent breath sounds on the affected side are hallmark signs of tension pneumothorax due to mediastinal shift and lung collapse.