Nokea
Which finding is commonly noted in the client with bladder cancer?
- A. Painless hematuria.
- B. Bladder spasms.
- C. Lower back pain.
- D. Urinary frequency.
Correct Answer: A
Rationale: Painless hematuria is a hallmark symptom of bladder cancer, often the earliest sign. Other symptoms may occur but are less specific.
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The client is receiving furosemide (Lasix) 80 mgm. Which is a sign of a possible complication of the administration of furosemide?
- A. Tachycardia
- B. Hypertension
- C. Polyuria
- D. Eupnea
Correct Answer: A
Rationale: Furosemide is a loop diuretic that can cause electrolyte imbalances, such as hypokalemia, which may lead to tachycardia. Hypertension is not a common complication; polyuria is an expected effect, not a complication; and eupnea (normal breathing) is unrelated.
A 2-month-old recently diagnosed with developmental dysplasia of the hip is beginning treatment with a Pavlik harness. Which instructions should the nurse reinforce to the parents? Select all that apply.
- A. Apply lotion under the straps to protect the skin.
- B. Dress the child in a shirt and knee socks under the straps.
- C. Lightly massage the skin under the straps daily.
- D. Place the diaper under the straps.
- E. Remove the harness during diaper changes.
Correct Answer: B,C,D
Rationale: Shirts and socks under straps prevent chafing, daily massage promotes circulation, and diapers under straps ensure hygiene. Lotion traps moisture, risking irritation. The harness should not be removed, even for diaper changes, to maintain correction.
Continuous bladder irrigation is prescribed for an adult who had bladder surgery; 1000 mL of irrigating solution was instilled in the last eight hours. The amount of drainage in the urine drainage bag for the last eight hours is 1700 mL. How much is the client's urine output for the last eight hours?
- A. 270 mL
- B. 700 mL
- C. 1700 mL
- D. 2799 mL
Correct Answer: B
Rationale: Urine output is calculated by subtracting instilled irrigation fluid (1000 mL) from total drainage (1700 mL), yielding 700 mL of actual urine.
The nurse is talking with the parent of a 2-year-old client who has a sunburn across the back and shoulders. Which of the following statements by the parent would indicate a correct understanding of sunburn care? Select all that apply.
- A. I will encourage my child to drink extra fluids.
- B. I will give my child aspirin to help relieve pain.
- C. I can allow my child to play outdoors with adequate sun protection.
- D. I can place cool compresses on my child's back to decrease discomfort
- E. I will apply hydrocortisone cream to the affected area and cover it with gauze dressings.
Correct Answer: A,C,D
Rationale: Extra fluids prevent dehydration, cool compresses soothe skin, and outdoor play with protection (sunscreen, clothing) is safe. Aspirin is avoided in children due to Reye's syndrome risk. Hydrocortisone isn't standard for sunburn; aloe or moisturizers are preferred.
A mother asks the nurse if she should be concerned about her child's tendency to stutter. What assessment data will be most useful in counseling the parent?
- A. Age of the child
- B. Sibling position in family
- C. Stressful family events
- D. Parental discipline strategies
Correct Answer: A
Rationale: Age of the child. Stuttering is often a normal part of language development in preschoolers, making age a critical factor.