Nokea
Which nursing intervention would be a priority for a patient receiving 3% saline maintenance fluids?
- A. Monitor serum HCO3-
- B. Monitor urine sodium
- C. Assess blood pressure
- D. Collect 24-hour urine output
Correct Answer: C
Rationale: 3% saline, a hypertonic solution, can cause fluid shifts, making blood pressure monitoring a priority.
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The nurse is educating a client about a transurethral resection of the prostate (TURP). Which of the following statements should the nurse make to the client regarding this surgery?
- A. This surgery will remove your entire prostate.
- B. You will have a nasogastric tube (NGT) left in place following this surgery.
- C. You will need to complete a bowel prep the night before this surgery.
- D. A urinary catheter will remain in place following this procedure.
Correct Answer: D
Rationale: A urinary catheter is used post-TURP to manage bleeding and ensure bladder drainage.
The nurse is reviewing the client's laboratory data. Which current prescription should the nurse clarify with the primary healthcare provider (PHCP)?
- A. Dextrose 5% in water (D5W)
- B. dexamethasone
- C. digoxin
- D. ergocalciferol
Correct Answer: A
Rationale: D5W is hypotonic and may worsen hyponatremia, requiring clarification in a client with low sodium levels.
The client is diagnosed with acute kidney failure. Which of the following is an appropriate psychosocial problem for the nurse to include in the care plan?
- A. Imbalanced nutrition: less than body requirements related to altered metabolic state and dietary restrictions.
- B. Anxiety related to the disease process and uncertainty of prognosis.
- C. Excess fluid volume related to compromised regulatory mechanisms secondary to acute renal failure.
- D. Risk for infection related to invasive procedures and an altered immune response secondary to renal failure.
Correct Answer: B
Rationale: Anxiety is a psychosocial issue related to the uncertainty and stress of acute kidney failure, unlike the other physiological options.
The nurse is caring for an assigned client. Which prescription requires clarification based on the laboratory data? See the exhibit. Select all that apply. Prescribed Medications: vancomycin 1-gram IVPB daily, furosemide 40 mg PO daily, 500 mL of 0.9% sodium chloride bolus x 1 dose, diltiazem XR 120 mg PO daily, Ketorolac 15 mg IV push every eight hours PRN pain. Laboratory Results: Sodium 145 mEq/L (145 mmol/L), Potassium 3.7 mEq/L (3.7 mmol/L), Calcium 9.3 mg/dL (2.32 mmol/L), BUN 25 mg/dL (8.93 mmol/L), Creatinine 2.1 mg/dL (185.64 umol/L)
- A. vancomycin 1-gram IVPB Daily
- B. furosemide 40 mg PO Daily
- C. 500 ml of 0.9% Saline IV Bolus x 1
- D. diltiazem XR 120 mg PO Daily
- E. ketorolac 15 mg IV Q 8 hours
Correct Answer: A,E
Rationale: Vancomycin (A) and Ketorolac (E) require clarification due to the elevated creatinine (2.1 mg/dL), indicating impaired renal function, which can increase the risk of toxicity for both drugs. Furosemide (B), saline bolus (C), and diltiazem (D) are not contraindicated with the given lab results.
The nurse is reviewing the assessment data for a client with acute glomerulonephritis (AGN). Which of the following would be an expected finding?
- A. Ketonuria
- B. Hematuria
- C. Polyuria
- D. Glycosuria
Correct Answer: B
Rationale: Hematuria is a hallmark of acute glomerulonephritis due to glomerular inflammation.