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What is the purpose of straining urine in a client with renal calculi?
- A. Detect blood.
- B. Identify stone composition.
- C. Measure urine volume.
- D. Prevent infection.
Correct Answer: B
Rationale: Straining urine captures stones for analysis to determine composition.
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A 56-year-old client who recently had a right pneumonectomy for lung cancer is admitted to the oncology unit with dyspnea and fever. The nurse should:
- A. Place the client on the left side.
- B. Position the client for postural drainage.
- C. Provide education on deep breathing exercises.
- D. Instruct the client to maintain bed rest with bathroom privileges.
Correct Answer: C
Rationale: Deep breathing exercises promote lung expansion and oxygenation, which are critical for a post-pneumonectomy client with dyspnea and fever, potentially indicating infection or compromised lung function.
Upon assessment of third degree heart block on the monitor, the nurse should first:
- A. Call a code.
- B. Begin cardiopulmonary resuscitation.
- C. Have transcutaneous pacing ready at the bedside.
- D. Prepare for defibrillation.
Correct Answer: C
Rationale: Third-degree heart block may require pacing. Having transcutaneous pacing ready is the first step to manage symptomatic bradycardia.
The nurse is assessing a client with heart failure who is receiving home health care monitoring using electronic devices including scales, blood pressure monitoring, and structured questions to which the client responds daily on a touch-screen monitor. The nurse reviews data obtained within the last 3 days. The nurse calls the client to follow up. The nurse should ask the client which of the following first:
- A. How are you feeling today?'
- B. Are you having shortness of breath?'
- C. Did you calibrate the scales before using them?'
- D. How much fluid did you drink during the last 24 hours?'
Correct Answer: B
Rationale: A 5-lb weight gain in 3 days and rising blood pressure suggest fluid retention. Asking about shortness of breath first assesses for pulmonary edema, a serious complication.
A nurse is assessing a client who has been admitted with a diagnosis of an obstruction in the small intestine. The nurse should assess the client for? Select all that apply.
- A. Projectile vomiting.
- B. Significant abdominal distention.
- C. Copious diarrhea.
- D. Rapid onset of dehydration.
- E. Increased bowel sounds.
Correct Answer: A,B,D,E
Rationale: Small intestinal obstruction can cause projectile vomiting (A), abdominal distention (B), rapid dehydration (D) due to fluid loss, and increased bowel sounds (E) proximal to the obstruction. Copious diarrhea (C) is less likely as stool passage is blocked. CN: Physiological adaptation; CL: Analyze
The nurse is assessing a client for neurologic impairment after a total hip replacement. Which of the following would indicate impairment in the affected extremity?
- A. Decreased distal pulse.
- B. Inability to move.
- C. Diminished capillary refill.
- D. Coolness to the touch.
Correct Answer: B
Rationale: Inability to move suggests nerve damage, a serious complication requiring immediate evaluation.