Nokea
The nurse is providing dietary instructions for a client who is being discharged after passing a calcium oxalate renal stone. Which food should the nurse instruct the client to avoid?
- A. Sweet potatoes.
- B. Spinach salad.
- C. Bananas.
- D. Fish.
Correct Answer: B
Rationale: Spinach is high in oxalates, contributing to calcium oxalate stone formation. Sweet potatoes, bananas, and fish are generally safe.
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When responding to a call light, the nurse finds a client with aggressive behaviors pacing, and restless in the room. The client shouts, 'What took you so long to get in here!' Which action should the nurse implement?
- A. Request backup from the staff.
- B. Stand in the doorway.
- C. Provide for personal space.
- D. Encourage the client to sit down.
Correct Answer: C
Rationale: Providing personal space reduces the perception of threat, helping de-escalate agitation safely.
A client with benign prostatic hyperplasia (BPH) is preparing for discharge following a transurethral needle ablation (TUNA). Which information should the nurse include in the discharge instructions?
- A. Use an incentive spirometer.
- B. Monitor the urinary stream for the decrease in output.
- C. Report when hematuria becomes pink-tinged.
- D. Restrict physical activities.
Correct Answer: C
Rationale: Reporting pink-tinged hematuria is critical to monitor for complications post-TUNA. Spirometry, urinary stream monitoring, and activity restriction are not specific to TUNA discharge.
A female client with bulimia is admitted to the mental health unit after she disclosed to a friend that she purges after meals. Which intervention should the nurse implement first?
- A. Provide a supportive, structured environment for meals.
- B. Assess weight, vital signs, potassium, and other electrolytes.
- C. Discuss alternative strategies for binging and purging.
- D. Monitor the client after meals for possible vomiting.
Correct Answer: B
Rationale: Assessing weight, vital signs, and electrolytes is critical to identify life-threatening complications of bulimia, taking precedence over other interventions.
A client is admitted to the hospital with suicidal ideation. When completing the health history and admission assessment interview, which client comment is most important for the nurse to document?
- A. I just feel like my life is filled with emptiness.'
- B. I have three firearms locked in a safe at home.'
- C. My daughter is the only reason I keep trying.'
- D. My panic attacks happen once every month.'
Correct Answer: B
Rationale: Access to firearms is a significant risk factor for suicide, making it critical to document. Other comments are relevant but less urgent.
History and Physical
Initial vital signs
The client is a 68-year-old with a history of diabetes, hypertension (HTN), coronary artery disease (CAD), and was recently diagnosed with end-stage renal disease (ERSD). She has been placed on hemodialysis three times a week for one month. She presents to the emergency department (ED) with fatigue, generalized weakness, muscle cramps, tingling sensation in arms and legs, and lightheadedness following 3 days of illness during which her husband reports she has complained of nausea and had poor appetite and was not able to go for her scheduled dialysis 2
Based on the client's subjective and objectives data, the nurse recognizes that she is having signs and symptoms of a sinus tachycardiahyperkalemiahypermagnesemiahypokalemia.
- A. Sinus tachycardia
- B. Hyperkalemia
- C. Hypermagnesemia
- D. Hypokalemia
Correct Answer: B
Rationale: The client's history of ESRD, missed dialysis, and symptoms (muscle cramps, tingling, weakness) suggest hyperkalemia, which can cause cardiac arrhythmias like sinus tachycardia. Other options are less consistent with the clinical picture.