Nokea
Which finding indicates a properly functioning ileal conduit?
- A. Clear urine output.
- B. Mucus in the urine.
- C. Dry stoma site.
- D. No urine output.
Correct Answer: B
Rationale: Mucus in the urine is normal due to the intestinal segment used in the conduit.
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Which is a priority assessment for the client in shock who is receiving an I.V. infusion of packed red blood cells and normal saline solution?
- A. Fluid balance.
- B. Anaphylactic reaction.
- C. Pain.
- D. Altered level of consciousness.
Correct Answer: B
Rationale: During a blood transfusion in a client in shock, the priority assessment is for an anaphylactic reaction, as transfusion reactions can be life-threatening and require immediate intervention. Fluid balance, pain, and consciousness are monitored but are secondary.
The client is scheduled to have an upper gastrointestinal tract series of x-rays. Following the x-rays, the nurse should instruct the client to:
- A. Take a laxative.
- B. Follow a clear liquid diet.
- C. Administer an enema.
- D. Take an antiemetic.
Correct Answer: A
Rationale: A laxative is typically recommended after an upper GI series to help eliminate the barium used in the procedure and prevent constipation.
A 25-year-old client taking hydroxychloroquine (Plaquenil) for rheumatoid arthritis reports difficulty seeing out of her left eye. Correct interpretation of this assessment finding indicates which of the following?
- A. Development of a cataract.
- B. Possible retinal degeneration.
- C. Part of the disease process.
- D. A coincidental occurrence.
Correct Answer: B
Rationale: Hydroxychloroquine can cause retinal toxicity, leading to vision changes. This is a known side effect requiring immediate medical evaluation.
A client who is to receive general anesthesia has a serum potassium level of 5.8 mEq/L. What should be the nurse's first response?
- A. Call the surgeon.
- B. Send the client to surgery.
- C. Make a note on the front of the chart.
- D. Notify the anesthesiologist.
Correct Answer: D
Rationale: A potassium level of 5.8 mEq/L indicates hyperkalemia, which can cause cardiac complications under general anesthesia. Notifying the anesthesiologist first ensures prompt evaluation and management to ensure patient safety.
A 75-year-old client who has been taking furosemide (Lasix) regularly for 4 months tells the nurse that he is having trouble hearing. What would be the nurse's best response to this statement?
- A. Tell the client that because he is 75 years old, it is inevitable that his hearing should begin to deteriorate.
- B. Have the client immediately report the hearing loss to his physician.
- C. Schedule the client for audiometric testing and a hearing aid.
- D. Tell the client that the hearing loss is only temporary; when his system adjusts to the furosemide, his hearing will improve.
Correct Answer: B
Rationale: Furosemide can cause ototoxicity, leading to hearing loss. The nurse should advise the client to report this to the physician promptly for further evaluation and management.