Nokea
Which comment is the best response the nurse can offer?
- A. You're a very nice person.
- B. You're a very nice person.
- C. You should expect this at your age.
- D. You're discouraged right now.
Correct Answer: D
Rationale: Acknowledging the client's feelings of discouragement validates their emotional state and opens the door for supportive communication.
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The client is admitted with a serum sodium level of 110 mEq/L. Which nursing intervention should be implemented?
- A. Encourage fluids orally.
- B. Administer 10% saline solution IVPB.
- C. Administer antidiuretic hormone intranasally.
- D. Place on seizure precautions.
Correct Answer: D
Rationale: Severe hyponatremia (110 mEq/L) increases seizure risk due to cerebral edema. Seizure precautions are the priority to ensure safety. Oral fluids or ADH may worsen hyponatremia, and 10% saline is not standard.
If the client makes the following statements, which information is most important to report to the physician before the client undergoes an intravenous pyelography (IVP)?
- A. The barium they give me to drink causes me to have concentration.
- B. I have a low tolerance for pain during procedures.
- C. I had a reaction when my gallbladder was X-rayed before.
- D. I get claustrophobic when I am put into that big round machine.
Correct Answer: C
Rationale: A previous reaction to a contrast dye, as implied by the gallbladder X-ray reaction, indicates a potential allergy risk, which must be reported before IVP.
The laboratory data reveal a calcium phosphate renal stone for a client diagnosed with renal calculi. Which discharge teaching intervention should the nurse implement?
- A. Encourage the client to eat a low-purine diet and limit foods such as organ meats.
- B. Explain the importance of not drinking water two (2) hours before bedtime.
- C. Discuss the importance of limiting vitamin D-enriched foods.
- D. Prepare the client for extracorporeal shock wave lithotripsy (ESWL).
Correct Answer: C
Rationale: Calcium phosphate stones are linked to hypercalciuria. Limiting vitamin D-enriched foods reduces calcium absorption, preventing recurrence. Low-purine diets are for uric acid stones, water restriction is contraindicated, and ESWL is a treatment, not teaching.
The client is experiencing urinary incontinence. Which intervention should the nurse implement?
- A. Teach the client to drink prune juice weekly.
- B. Encourage the client to eat a high-fiber diet.
- C. Discuss the need to urinate every six (6) hours.
- D. Explain the importance of wearing cotton underwear.
Correct Answer: B
Rationale: A high-fiber diet prevents constipation, which can exacerbate incontinence by pressuring the bladder. Prune juice is too specific, voiding every 6 hours is too infrequent, and cotton underwear is secondary.
The client is reporting chills, fever, and left costovertebral pain. Which diagnostic test should the nurse expect the HCP to prescribe first?
- A. A midstream urine for culture.
- B. A sonogram of the kidney.
- C. An intravenous pyelogram for renal calculi.
- D. A CT scan of the kidneys.
Correct Answer: A
Rationale: Chills, fever, and costovertebral pain suggest pyelonephritis. A midstream urine culture is the first test to identify the causative organism. Imaging (sonogram, IVP, CT) is secondary to confirm complications or other diagnoses.