Nokea
What is a goal of care for a client with acute renal failure?
- A. Maintain urine output of 30 mL/hour.
- B. Keep potassium above 5.5 mEq/L.
- C. Increase protein intake.
- D. Limit ambulation.
Correct Answer: A
Rationale: Maintaining adequate urine output indicates improving renal function.
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The nurse is discussing ocular disorders with a group of nursing students. Which of the following statements would be correct for the nurse to make? Select all that apply.
- A. Cataracts are caused by increased ocular pressure (IOP).
- B. Graves' disease may cause exophthalmos.
- C. Macular degeneration is manifested by loss of peripheral vision.
- D. Angle-closure glaucoma is manifested by headache and eye pain.
- E. Hyphema results in increased aqueous humor in the anterior chamber.
Correct Answer: B,D
Rationale: Graves' disease can cause exophthalmos (bulging eyes) due to autoimmune inflammation. Angle-closure glaucoma presents with headache and eye pain due to sudden increases in intraocular pressure. Cataracts are caused by lens opacity, not IOP. Macular degeneration affects central vision, not peripheral. Hyphema is blood in the anterior chamber, not increased aqueous humor.
After an intravenous pyelogram (IVP), the nurse should not include incorporating which of the following measures into the client's plan of care?
- A. Maintaining bed rest.
- B. Encouraging adequate fluid intake.
- C. Assessing for hematuria.
- D. Administering a laxative.
Correct Answer: D
Rationale: Administering a laxative is unnecessary post-IVP, as it does not aid recovery or contrast excretion, unlike fluid intake or hematuria assessment.
The nurse is caring for a client who is receiving prescribed ketorolac. Which of the following client findings would indicate a therapeutic response? Select all that apply.
- A. Decreased pain
- B. Increased urinary output
- C. Decreased blood pressure
- D. Decreased temperature
- E. Increased muscle coordination
Correct Answer: A,D
Rationale: Ketorolac, an NSAID, reduces pain and inflammation, which can lower temperature in febrile clients. It does not directly affect urinary output, blood pressure, or muscle coordination.
A nurse is assessing a female who is receiving the second administration of chemotherapy for breast cancer. When obtaining this client's health history, what is the most important information the nurse should obtain?
- A. Has your hair been falling out in clumps?
- B. Have you had nausea or vomiting?
- C. Have you been sleeping at night?
- D. Do you have your usual energy level?
Correct Answer: B
Rationale: Nausea and vomiting are critical to assess during chemotherapy, as they can lead to dehydration, malnutrition, and treatment delays if not managed promptly.
A client uses timolol maleate (Timoptic) eyedrops. The expected outcome of this beta-adrenergic blocker is to control glaucoma by:
- A. Constricting the pupils.
- B. Dilating the canals of Schlemm.
- C. Reducing aqueous humor formation.
- D. Improving the ability of the ciliary muscle to contract.
Correct Answer: C
Rationale: Timolol maleate, a beta-adrenergic blocker, reduces intraocular pressure by decreasing the production of aqueous humor in the eye.