Nokea
The nurse is caring for a client with overflow urinary incontinence related to diabetic neuropathy. Which of the following interventions are appropriate?
- A. Decrease fluid intake to 1 glass with each meal and at bedtime
- B. Encourage the client to bear down while attempting to void
- C. Inspect the perineal area for evidence of skin breakdown
- D. Measure postvoid residual volumes as prescribed
- E. Tell the client to wait 30 seconds after voiding and then attempt to void again
Correct Answer: C,D,E
Rationale: Inspecting for skin breakdown (C), measuring postvoid residuals (D), and double voiding (E) manage overflow incontinence. Restricting fluids (A) risks dehydration, and bearing down (B) may worsen incontinence.
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Which of the following instructions should be included for the client taking calcium supplements?
- A. The client should take her calcium with meals.
- B. The client should take all her daily calcium supplement at one time.
- C. The client should take her calcium supplement after meals to prevent stomach upset.
- D. The client can use calcium-based antacids to supplement her diet.
Correct Answer: A
Rationale: Taking calcium supplements with meals enhances absorption and reduces gastrointestinal upset.
The nurse administers cimetidine (Tagamet) to a 79 year-old male with a gastric ulcer. Which parameter may be affected by this drug, and should be closely monitored by the nurse?
- A. Blood pressure
- B. Liver function
- C. Mental status
- D. Hemoglobin
Correct Answer: C
Rationale: The elderly are at risk for developing confusion when taking cimetidine, a drug that interacts with many other medications.
A client is admitted for hemodialysis. Which abnormal lab value would the nurse anticipate not being improved by hemodialysis?
- A. Low hemoglobin
- B. Hypernatremia
- C. High serum creatinine
- D. Hyperkalemia
Correct Answer: A
Rationale: Low hemoglobin. Hemodialysis corrects electrolyte imbalances but does not improve anemia.
A 2-year-old who swallowed an overdose of adult cough syrup is being discharged from the emergency department. The parent says to the nurse, 'From now on, I'm going to store all medicines in my top dresser drawer.' Which is the best response by the nurse?
- A. Can you lock your dresser drawer?
- B. Make sure all of your medicines have childproof caps.
- C. That sounds like a safe plan.
- D. You need to keep an eye on your child at all times.
Correct Answer: A
Rationale: A locked drawer (A) ensures safety. Childproof caps (B) are helpful but insufficient alone. The plan (C) is unsafe without a lock, and constant supervision (D) is unrealistic.
A nurse prepares to care for a 4 year-old newly admitted for rhabdomyosarcoma. The nurse should alert the staff to pay more attention to the function of which area of the body?
- A. the muscles
- B. the cerebellum
- C. the kidneys
- D. the leg bones
Correct Answer: A
Rationale: the muscles. Rhabdomyosarcoma is the most common children's soft tissue sarcoma. It originates in striated (skeletal) muscles and can be found anywhere in the body. The clue is in the middle of the word -- 'myo' --which typically means muscle.