The nurse reviews a client's laboratory data. Which laborato...

The following scenario applies to the next 1 items
The nurse in the medical-surgical unit is caring for a client following a transurethral resection of the prostate (TURP).
Item 1 of 1
Nurses’ Notes
1241: The client arrived at the medical-surgical unit six hours post-operative from a TURP. The client was alert and oriented to person, place, time, and situation. The client has a three-way indwelling urinary catheter and is continuously irrigated with isotonic saline. Urine output is ketchup-like with medium to large clots. The client reports the need to urinate and reported pressure in the pelvic region, described as spasms.

Intake and Output
Intake – Continuous bladder irrigation: 550 mL
Output – Indwelling catheter: 975 mL
Vital Signs
1257:
Blood Pressure 100/60 mm Hg
Temperature 98° F (36.7° C)
Heart rate 110/min
Respiratory rate 19 breaths per minute
Oxygen saturation 95% on room air

The client is demonstrating signs and symptoms of.

A. urinary catheter obstruction
B. hyponatremia
C. shock
D. urinary tract infection

Correct Answer: A

Rationale: Ketchup-like urine with clots and pelvic pressure post-TURP indicate catheter obstruction.

Which nursing assessment finding are consistent with hypocalcemia? Select all that apply.

A. Chvostek's sign
B. Grey-Turner's sign
C. Homan's sign
D. Trousseau's sign
E. Numbness and tingling of the fingers and toes

Correct Answer: A,D,E

Rationale: Hypocalcemia causes Chvostek's sign, Trousseau's sign, and numbness/tingling due to neuromuscular irritability.

The nurse is assessing a client who was just diagnosed with acute pyelonephritis. Which of the following findings should the nurse expect to observe? Select all that apply.

A. Costovertebral angle tenderness
B. Jugular venous distention
C. Fever and chills
D. Urinary retention
E. Dysuria

Correct Answer: A,C,E

Rationale: Pyelonephritis causes costovertebral angle tenderness, fever, chills, and dysuria due to kidney inflammation and infection.

The following scenario applies to the next 6 items.
The nurse in the emergency department (ED) is caring for a 57-year-old male client.
Item 3 of 6
History and Physical
A 57-year-old male client with stage three small cell lung cancer. The client had suddenly become disoriented and did not recognize his family members and relatives. He reports severe lower extremity weakness and has had three episodes of diarrhea in the past four hours. The client is undergoing 6 cycles of chemotherapy with cisplatin and etoposide. He is currently taking a 14-day course of 15 mg of prednisone. He is on his third day of steroid treatment. He has a medical history of dyslipidemia and advanced chronic obstructive pulmonary disease.

Nurses' Notes
0759: Client is completely disoriented and required maximum assistance to the stretcher because of unsteady gait. Lung sounds clear bilaterally. Alopecia noted. Skin is warm and dry and normal for ethnicity. Peripheral pulses 2+. No skin tenting. Hyperactive bowel sounds in all quadrants. 20-gauge peripheral vascular access device placed in the left antecubital space. T 97.8° F (36.6° C) P 88 RR 21 BP 123/68 Pulse oximetry reading 91% on room air.

Laboratory Results
• Hemoglobin 14 g/dL [14-18 g/dL (140–180 g/L)]
• Hematocrit 42% (0.42) [42-52% (0.42-0.52)]
• White Blood Cell 11,000 mm3 [5-10 mm3]
• Platelet Count 140,000 mm3 [150-400 mm3 (150–400 × 109/L)]
• Glucose 139 mg/dL (7.72 mmol/L) [70–110 mg/dL (4-6 mmol/L)]
• Sodium 116 mEq/L [136–145 mEq/L (mmol/L)]
• Potassium 3.3 mEq/L [3.5–5.0 mEq/L (mmol/L)]
• Creatinine 0.7 mg/dL (61.88 mmol/L) [0.6–1.2 mg/dL (53–106 mmol/L)]
• Blood Urea Nitrogen 8 mg/dL (2.86 mmol/L) [10–20 mg/dL (3.6–7.1 mmol/L)]
• Serum Osmolality 277 mOsm/kg [285-295 mOsm/kg (285–295 mmol/kg)]

The client is demonstrating manifestations consistent with......... due to.......

A. Cushing's syndrome
B. diabetes insipidus
C. syndrome of inappropriate antidiuretic hormone
D. advanced chronic obstructive pulmonary disease.
E. small cell lung cancer.
F. corticosteroid usage.

Correct Answer: C,E

Rationale: SIADH, often caused by small cell lung cancer, leads to hyponatremia and neurological symptoms like disorientation.

The nurse is placing a client with chronic kidney disease on a cardiac monitor. What is the reason for this action?

A. Clients with chronic kidney disease are prone to hypertension
B. Hyperkalemia may result in dysrhythmias
C. Cardiac monitoring is necessary to evaluate the need for hemodialysis
D. Clients with chronic kidney disease may experience false episodes of asystole

Correct Answer: B

Rationale: Hyperkalemia, common in CKD, can cause dysrhythmias, necessitating cardiac monitoring.

Urinary Elimination NCLEX RN Questions Related

Correct Answer: B,C,D,E