Nokea
The nurse is caring for an adult who has kidney stones. Which action is essential for the nurse to take?
- A. Take blood pressure frequently
- B. Keep the client on bed rest
- C. Position the client supine
- D. Strain all urine
Correct Answer: D
Rationale: Straining urine captures kidney stones for analysis, guiding treatment. Blood pressure, bed rest, or positioning are not primary.
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A client has returned to the floor from thyroidectomy surgery.
After a client has returned to the floor from thyroidectomy surgery, it is MOST important for the nurse to take which of the following actions?
- A. Monitor vital signs every four hours.
- B. Observe for frequent swallowing.
- C. Monitor for signs of respiratory distress every hour.
- D. Position the client in the supine position.
Correct Answer: C
Rationale: Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? Yes. Determine what assessment is being made in each answer choice. (1) assessment is not specific to this surgery (2) assessment, method used to monitor for postoperative hemorrhage in a tonsillectomy client (3) correct-assessment, after surgery, swelling can occur, which causes respiratory distress (4) implementation, head of the bed should be elevated
The nurse is teaching a client with a new diagnosis of gout about colchicine. Which of the following instructions should the nurse include?
- A. Take the medication with grapefruit juice.
- B. Report any diarrhea.
- C. Stop the medication if gout attacks cease.
- D. Avoid regular joint exams.
Correct Answer: B
Rationale: Diarrhea is a serious colchicine side effect, indicating potential toxicity. Options A, C, and D are incorrect.
The infant of a diabetic mother has a blood glucose of 90 mg/dL and a serum calcium level of 7.0 mg/dL. The nurse should anticipate that which of the following medications would be administered IV?
- A. Insulin.
- B. Glucose.
- C. Phenobarbital.
- D. Calcium gluconate.
Correct Answer: D
Rationale: Hypocalcemia (7.0 mg/dL) in infants of diabetic mothers risks tetany; calcium gluconate is indicated. Options A, B, and C are inappropriate.
When assessing a client who has just undergone a cardioversion, the practical nurse (LPN) finds the respirations are 12/minute. Which action should the nurse take first?
- A. Try to vigorously stimulate normal breathing
- B. Ask the RN to assess the vital signs
- C. Measure the pulse oximetry
- D. Continue to monitor respirations
Correct Answer: D
Rationale: Continue to monitor respirations. A rate of 12/minute is acceptable post-cardioversion, requiring no immediate intervention.
A client with a marked depression of T cells.
To promote safety in the environment of a client with a marked depression of T cells, the nurse should
- A. keep a linen hamper immediately outside the room.
- B. restrict eating utensils to spoons made of plastic.
- C. provide masks for anyone entering the room.
- D. remove any standing water left in containers or equipment.
Correct Answer: D
Rationale: Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) protocol for handling soiled articles is accomplished within universal guidelines with double biohazard bags (2) universal precautions and client protection may call for plastic utensils, but not just spoons (3) not protocol unless the client has an active pulmonary infection (4) correct-water should not be allowed to stand in containers, such as respiratory or suction equipment, because this could act as a culture medium