Nokea
The nurse teaches the client with an ileal conduit measures to prevent a urinary loss. Which of the following measures would be most effective?
- A. Avoid people with respiratory tract infections.
- B. Maintain a daily fluid intake of 2,000 to 3,000 mL.
- C. Use sterile technique to change the appliance.
- D. Irrigate the stoma daily.
Correct Answer: B
Rationale: Maintaining high fluid intake (2,000-3,000 mL) prevents urinary stasis and infection, the most effective measure for reducing urinary loss risk.
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Which of the following medications should be available to provide emergency treatment if a client develops tetany after a subtotal thyroidectomy?
- A. Sodium phosphate.
- B. Calcium gluconate.
- C. Echothiophate iodide.
- D. Sodium bicarbonate.
Correct Answer: B
Rationale: Calcium gluconate is used to treat tetany by correcting hypocalcemia, which causes muscle spasms and tingling.
Which intervention is contraindicated for a client with a seizure disorder?
- A. Provide a safe environment.
- B. Use a padded tongue depressor.
- C. Administer prescribed anticonvulsants.
- D. Monitor post-seizure status.
Correct Answer: B
Rationale: Using a padded tongue depressor is contraindicated as it can cause injury during a seizure.
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.
The client is diagnosed in the emergency department with a detached retina in the right eye. The nurse should do which of the following first?
- A. Apply compresses to the eye.
- B. Administer analgesics to reduce pain.
- C. Remove all bed pillows.
- D. Promote measures that limit mobility.
Correct Answer: D
Rationale: Limiting mobility is the priority to prevent further detachment of the retina by reducing eye movement and strain until surgical intervention can be performed.
Which of the following increases the risk of having a large abdominal aortic aneurysm rupture?
- A. Anemia
- B. Dehydration
- C. High blood pressure
- D. Hyperglycemia
Correct Answer: C
Rationale: High blood pressure increases wall stress in a large abdominal aortic aneurysm, elevating the risk of rupture per Laplace's law (wall tension ˆ pressure × radius). Anemia, dehydration, and hyperglycemia do not directly increase rupture risk.