Nokea
Which statement by the client provides the best evidence that he understands the potential side effects associated with hormonal therapy? Select all that apply.
- A. My breasts may enlarge.
- B. I may have spontaneous erections.
- C. My sperm count will be higher.
- D. I'll have strong sexual urges.
- E. My voice may become higher.
- F. I may have a rapid weight gain.
Correct Answer: A,F
Rationale: Estradiol can cause gynecomastia (breast enlargement) and weight gain, which are expected side effects.
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The nurse is caring for the client recovering from a percutaneous renal biopsy. Which data indicate the client is complying with client teaching?
- A. The client is lying flat in the saline position.
- B. The client continues oral fluids restriction while on bedrest.
- C. The client uses the bedside commode to urinate.
- D. The client refuses to ask for any pain medication.
Correct Answer: A
Rationale: Post-renal biopsy, lying flat (supine, assuming 'saline' is a typo) prevents bleeding complications, indicating compliance. Fluid restriction is unnecessary, using a commode risks bleeding, and refusing pain meds is unrelated.
Because of the client's impaired urine elimination, which potential skin problem will require additional team planning?
- A. Reduced perspiration
- B. Extreme oiliness
- C. Loss of skin turgor
- D. Pronounced itching
Correct Answer: D
Rationale: Pronounced itching is a common skin problem in renal failure due to uremia and phosphate accumulation.
The nurse is observing the UAP providing direct care to a client with an indwelling catheter. Which data warrant immediate intervention by the nurse?
- A. The UAP secures the tubing to the client’s leg with tape.
- B. The UAP provides catheter care with the client’s bath.
- C. The UAP puts the collection bag on the client’s bed.
- D. The UAP cares for the catheter after washing the hands.
Correct Answer: C
Rationale: Placing the collection bag on the bed risks contamination and infection, as it should be below bladder level and off surfaces. Securing tubing, providing care during bathing, and hand washing are appropriate.
The client diagnosed with ARF has a serum potassium level of 6.8 mEq/L. Which collaborative treatment should the nurse anticipate for the client?
- A. Administer a phosphate binder.
- B. Type and crossmatch for whole blood.
- C. Assess the client for leg cramps.
- D. Prepare the client for dialysis.
Correct Answer: D
Rationale: A potassium level of 6.8 mEq/L indicates severe hyperkalemia, which can cause cardiac arrhythmias. Dialysis is the most effective treatment to rapidly lower potassium in ARF. Phosphate binders, blood transfusions, or assessing cramps do not address hyperkalemia directly.
After the TURP, which assessment finding would the nurse expect to observe during the immediate postoperative period?
- A. Light pink to clear urine
- B. Second sediments in urine
- C. Decreased volume of urine
- D. Grossly bloody urine
Correct Answer: D
Rationale: Grossly bloody urine is expected immediately after TURP due to surgical trauma to the prostate.