Nokea
When assessing the urinary output of a client who has had extracorporeal lithotripsy, the nurse can expect to find:
- A. Cherry-red urine that gradually becomes clearer
- B. Orange-tinged urine containing particles of calculi
- C. Dark red urine that becomes cloudy in appearance
- D. Dark, smoky-colored urine with high specific gravity
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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A client with dysphagia and at risk for aspiration needs care planning. Which intervention should the nurse include in the plan?
- A. Encourage the client to drink thickened liquids.
- B. Instruct the client to swallow with chin tucked.
- C. Provide the client with a cup with a lid.
- D. Place the client in Fowler's position for meals.
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Which of the following Nursing diagnosis is INCORRECT?
- A. Fluid volume deficit R/T Diarrhea
- B. High risk for injury R/T Absence of side rails
- C. Possible ineffective coping R/T Loss of loved one
- D. Self esteem disturbance R/T Effects of surgical removal of the leg
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
When assessing a client with diabetes mellitus experiencing DKA, which of the following findings should the nurse expect?
- A. Tremors
- B. Urine retention
- C. Kussmaul respirations
- D. Bradypnea
Correct Answer: C
Rationale: Kussmaul respirations are a type of deep and labored breathing pattern associated with severe metabolic acidosis, commonly observed in diabetic ketoacidosis (DKA). In DKA, the body tries to compensate for the acidic environment by increasing the respiratory rate, resulting in Kussmaul respirations. This helps eliminate excess carbon dioxide and reduce the acidity of the blood.
The nurse is assisting in planning care for a client scheduled for insertion of a tracheostomy. Which equipment should the nurse plan to have at the bedside when the client returns from surgery?
- A. Obturator
- B. Oral airway
- C. Epinephrine
- D. Tracheostomy tube with the next larger size
Correct Answer: A
Rationale: Post-tracheostomy, the obturator (A) is essential at the bedside to reinsert the tube if dislodged, ensuring airway patency. An oral airway (B) is irrelevant for tracheostomy patients. Epinephrine (C) treats allergic reactions, not routine needs. A larger tracheostomy tube (D) isn't standard emergency equipment. A is correct. Rationale: The obturator facilitates immediate tube replacement, critical in the first 72 hours before a tract forms, preventing airway loss, a priority per surgical nursing standards over other less relevant items.
Which of the following statement is TRUE about livor mortis?
- A. Cooling of the body after death
- B. Stiffening of the body after death
- C. Blood pooling on the dependent part of the body
- D. Shrinking of the body due to loss of fluid
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.