Nokea
To avoid erroneous test results caused by the manipulation of the prostate, the nurse should be included in diagnostic test before the client's rectal examination?
- A. Kidneys, ureters, bladder X-ray
- B. Needle biopsy of the prostate gland
- C. Prostate specific antigen (PSA) test
- D. Transrectal ultrasound examination
Correct Answer: C
Rationale: The PSA test should be done before rectal examination, as manipulation can elevate PSA levels, leading to false results.
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The client is two (2) days postureterosigmoidostomy for cancer of the bladder. Which assessment data warrant notification of the HCP by the nurse?
- A. The client complains of pain at a '3,' 30 minutes after being medicated.
- B. The client complains it hurts to cough and deep breathe.
- C. The client ambulates to the end of the hall and back before lunch.
- D. The client is lying in a fetal position and has a rigid abdomen.
Correct Answer: D
Rationale: A rigid abdomen and fetal position suggest peritonitis or other serious complications (e.g., anastomotic leak) post-ureterosigmoidostomy, requiring immediate HCP notification. Mild pain, coughing discomfort, and ambulation are less urgent.
The client diagnosed with renal calculi is scheduled for lithotripsy. Which postprocedure nursing task is the most appropriate to delegate to the UAP?
- A. Monitor the amount, color, and consistency of urine output.
- B. Teach the client about care of the indwelling Foley catheter.
- C. Assist the client to the car when being discharged home.
- D. Take the client’s postprocedural vital signs.
Correct Answer: C
Rationale: Assisting the client to the car is a non-clinical task within the UAP’s scope. Monitoring urine, teaching catheter care, and taking vital signs require nursing judgment and are not delegable.
The client who is post-thyroidectomy complains of numbness and tingling around the mouth and the tips of the fingers. Which intervention should the nurse implement first?
- A. Notify the health-care provider immediately.
- B. Tap the cheek about two (2) cm anterior to the earlobe.
- C. Check the serum calcium and magnesium levels.
- D. Prepare to administer calcium gluconate IVP.
Correct Answer: C
Rationale: Numbness and tingling post-thyroidectomy suggest hypocalcemia due to parathyroid injury. Checking serum calcium and magnesium levels confirms the diagnosis before treatment. Notification, Chvostek’s sign, or calcium administration follow confirmation.
The client diagnosed with diabetes insipidus weighed 180 pounds when the daily weight was taken yesterday. This morning’s weight is 175.6 pounds. One liter of fluid weighs approximately 2.2 pounds. How much fluid has the client lost?
Correct Answer: 2 L
Rationale: Weight loss: 180 - 175.6 = 4.4 pounds. Fluid loss: 4.4 pounds ÷ 2.2 pounds/L = 2 L. This calculation accounts for fluid loss typical in diabetes insipidus due to excessive urination.
Which problem is the nurse's immediate concern after kidney transplant surgery?
- A. Risk for infection
- B. Fluid overload
- C. Hypotension
- D. Pain management
Correct Answer: A
Rationale: Risk for infection is the immediate concern post-transplant due to immunosuppression, which increases susceptibility to infections.