Nokea
Which dietary modification is appropriate for a client with calcium oxalate stones?
- A. Increase dairy intake.
- B. Limit spinach consumption.
- C. Reduce fluid intake.
- D. Eat more red meat.
Correct Answer: B
Rationale: Spinach is high in oxalates, which contribute to calcium oxalate stone formation.
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A client receiving radiation to the head and neck is experiencing stomatitis. The nurse should recommend:
- A. Evaluation by a dentist.
- B. Alcohol-based mouth wash rinses.
- C. Artificial saliva.
- D. Vigorous brushing of teeth after each meal.
Correct Answer: C
Rationale: Artificial saliva helps relieve dry mouth and discomfort from stomatitis, a common side effect of head and neck radiation, by maintaining oral moisture.
Bethanechol (Urecholine) has been ordered for a client with gastroesophageal reflux disease (GERD). The nurse should assess the client for which of the following adverse effects?
- A. Constipation.
- B. Urinary urgency.
- C. Hypertension.
- D. Dry oral mucosa.
Correct Answer: B
Rationale: Bethanechol, a cholinergic agent, can cause urinary urgency as an adverse effect due to its stimulation of smooth muscle contraction, including in the bladder.
The client's blood urea nitrogen (BUN) concentration is elevated in acute renal failure. What is the likely cause of this finding?
- A. Fluid retention.
- B. Hemolysis of red blood cells.
- C. Below-normal metabolic rate.
- D. Reduced renal blood flow.
Correct Answer: D
Rationale: Reduced renal blood flow impairs urea excretion, causing elevated BUN levels in acute renal failure.
The nurse is developing a discharge teaching plan for a client who underwent a repair of abdominal aortic aneurysm 4 days ago. The nurse reviews the client's chart for information about the client's history. Key findings are noted in the chart below. Based on the data and expected outcomes, which should the nurse emphasize in the teaching plan?
- A. Food intake
- B. Fluid volume
- C. Skin integrity
- D. Tissue perfusion
Correct Answer: D
Rationale: Post-AAA repair, tissue perfusion is critical to ensure graft patency and prevent ischemia in the lower extremities or organs. Teaching should emphasize signs of poor perfusion (e.g., pain, pallor, pulselessness) and follow-up care. Food, fluid, and skin integrity are less urgent.
A client undergoing a mastectomy asks why she needs to sign a blood transfusion consent form. The nurse's best response is:
- A. œIt's a precaution in case of excessive bleeding during surgery.'
- B. œAll surgical clients must sign this form.'
- C. œIt ensures you receive blood if you request it.'
- D. œIt's required to test your blood type before surgery.'
Correct Answer: A
Rationale: Explaining that the consent is a precaution for potential bleeding addresses the client's question accurately and promotes informed consent.