Nokea
Which of the following would be an expected outcome for a client recovering from an upper respiratory tract infection? The client will:
- A. Maintain a fluid intake of 800 mL every 24 hours.
- B. Experience chills only once a day.
- C. Cough productively without chest discomfort.
- D. Experience less nasal obstruction and discharge.
Correct Answer: D
Rationale: An expected outcome for recovery from an upper respiratory tract infection is reduced nasal obstruction and discharge, indicating resolution of inflammation and infection. A fluid intake of 800 mL is too low; 1,500–2,000 mL is more appropriate. Chills are not a typical measure of recovery. Productive coughing without discomfort may occur but is less specific than reduced nasal symptoms.
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What is the nurse's best response to a client with MS experiencing fatigue?
- A. Limit all activities.
- B. Schedule rest periods.
- C. Increase fluid intake.
- D. Avoid all exercise.
Correct Answer: B
Rationale: Scheduling rest periods helps manage fatigue while supporting activity in multiple sclerosis.
A client who has been diagnosed with bladder cancer is scheduled for an ileal conduit. Preoperatively, the nurse reinforces the client's understanding of the surgical procedure by explaining that an ileal conduit:
- A. Is a temporary procedure that can be reversed later.
- B. Diverts urine into the sigmoid colon, where it is expelled through the rectum.
- C. Conveys urine from the ureters to a stoma opening on the abdomen.
- D. Creates an opening in the bladder that allows urine to drain into an external pouch.
Correct Answer: C
Rationale: An ileal conduit diverts urine from the ureters to an abdominal stoma, where it is collected in an external pouch, a permanent procedure for bladder cancer management.
Which of the following adverse effects would the nurse expect the client to exhibit in the event of too rapid an infusion of TPN solution?
- A. Negative nitrogen balance.
- B. Circulatory overload.
- C. Hypoglycemia.
- D. Hypokalemia.
Correct Answer: B
Rationale: Too rapid an infusion of TPN can cause circulatory overload due to the high volume and osmolarity of the solution. Negative nitrogen balance, hypoglycemia, or hypokalemia are not directly caused by rapid infusion. CN: Pharmacological and parenteral therapies; CL: Analyze
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.
Which of the following nursing interventions is likely to provide the most relief from the pain associated with renal colic?
- A. Applying moist heat to the flank area.
- B. Administering meperidine (Demerol).
- C. Encouraging high fluid intake.
- D. Maintaining complete bed rest.
Correct Answer: B
Rationale: Meperidine, an opioid, provides the most effective relief for the severe pain of renal colic by directly addressing pain pathways.