Nokea
The nurse should assess the client with bladder cancer for which of the following?
- A. Suprapubic pain.
- B. Dysuria.
- C. Painless hematuria.
- D. Urine retention.
Correct Answer: C
Rationale: Painless hematuria is a hallmark symptom of bladder cancer, often presenting as the initial sign due to tumor growth causing bleeding without associated pain.
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The nurse administers theophylline (TheoDur) to a client. To evaluate the effectiveness of this medication, which of the following drug actions should the nurse anticipate?
- A. Suppression of the client's respiratory infection.
- B. Decrease in bronchial secretions.
- C. Relaxation of bronchial smooth muscle.
- D. Thinning of tenacious, purulent sputum.
Correct Answer: C
Rationale: Theophylline relaxes bronchial smooth muscle, relieving bronchospasm in COPD. It does not suppress infection, reduce secretions, or thin sputum.
The nurse is planning care for an 80-year-old client with a pressure ulcer (see figure). The nurse should do which of the following? Select all that apply.
- A. Elevate the head of the bed to 50 degrees.
- B. Obtain daily cultures.
- C. Cover with protective dressing.
- D. Reposition the client every 2 hours.
- E. Request an alternating-pressure mattress.
Correct Answer: C,D,E
Rationale: Protective dressings, frequent repositioning, and pressure-relieving mattresses promote healing and prevent worsening of pressure ulcers. High head elevation increases shear, and daily cultures are unnecessary unless infection is suspected.
A client who has had a total hip replacement has a dislocated hip prosthesis. The nurse should first?
- A. Stabilize the leg with Buck's traction.
- B. Apply an ice pack to the affected hip.
- C. Position the client toward the opposite side of the hip.
- D. Notify the orthopedic surgeon.
Correct Answer: D
Rationale: Notifying the surgeon is the priority, as dislocation requires urgent medical intervention.
Which statement by a client with a new ileal conduit indicates a need for further teaching?
- A. I will empty the pouch when it is one-third full.
- B. I can use vinegar to clean my appliance.
- C. I should drink 2,000 mL of fluid daily.
- D. I will wear tight clothing to hide the pouch.
Correct Answer: D
Rationale: Tight clothing can irritate the stoma and impair appliance function, indicating a misunderstanding of proper care.
Which of the following should be a priority focus of care for a client experiencing an exacerbation of Crohn's disease?
- A. Encouraging regular ambulation.
- B. Promoting bowel rest.
- C. Maintaining current weight.
- D. Decreasing episodes of rectal bleeding.
Correct Answer: B
Rationale: Promoting bowel rest is the priority during a Crohn's exacerbation to reduce inflammation and symptoms. Ambulation, weight maintenance, and reducing bleeding are secondary to resting the bowel. CN: Physiological adaptation; CL: Synthesize