Nokea
Which assessment finding is expected in the oliguric phase of acute renal failure?
- A. Weight gain.
- B. Hypotension.
- C. Clear urine.
- D. Low BUN levels.
Correct Answer: A
Rationale: Weight gain occurs due to fluid retention in the oliguric phase.
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The primary goal for the client with Buerger's disease is to prevent:
- A. Embolus formation
- B. Fat embolus formation
- C. Thrombophlebitis
- D. Gangrene
Correct Answer: D
Rationale: The primary goal in Buerger's disease is to prevent gangrene, as the condition causes severe arterial and venous inflammation, leading to occlusion and tissue ischemia. Smoking cessation and vasodilation are key to avoiding tissue necrosis. Embolus, fat embolus, or thrombophlebitis are less specific concerns.
A client who has been diagnosed with bladder cancer is scheduled for an ileal conduit. Preoperatively, the nurse reinforces the client's understanding of the surgical procedure by explaining that an ileal conduit:
- A. Is a temporary procedure that can be reversed later.
- B. Diverts urine into the sigmoid colon, where it is expelled through the rectum.
- C. Conveys urine from the ureters to a stoma opening on the abdomen.
- D. Creates an opening in the bladder that allows urine to drain into an external pouch.
Correct Answer: C
Rationale: An ileal conduit diverts urine from the ureters to an abdominal stoma, where it is collected in an external pouch, a permanent procedure for bladder cancer management.
A client receiving TPN reports sudden chest pain and dyspnea. Which action should the nurse take first?
- A. Stop the TPN infusion.
- B. Administer oxygen as ordered.
- C. Notify the physician.
- D. Check the client's blood glucose.
Correct Answer: C
Rationale: Sudden chest pain and dyspnea in a client receiving TPN may indicate a serious complication like an air embolism or infection, requiring immediate physician notification. Stopping the infusion or checking glucose is premature, and oxygen requires an order. CN: Physiological adaptation; CL: Synthesize
After the administration of t-PA, the assessment priority is to:
- A. Monitor the client for chest pain.
- B. Monitor for fever.
- C. Monitor the 12-lead electrocardiogram (ECG) every 4 hours.
- D. Monitor breath sounds.
Correct Answer: A
Rationale: Monitoring for chest pain post-t-PA assesses for reperfusion success or reocclusion, a priority to ensure effective thrombolysis and myocardial perfusion.
The nurse is discussing infiltration with a group of students. It would be appropriate for the nurse to describe this complication as
- A. a vesicant drug entering into intradermal tissue.
- B. a non-vesicant drug entering subcutaneous tissue.
- C. a vesicant drug entering into subcutaneous tissue.
- D. a vesicant drug entering the muscle by injection.
Correct Answer: B
Rationale: Infiltration involves non-vesicant fluid leaking into subcutaneous tissue, causing swelling and discomfort.