Nokea
While assessing a client following lithotripsy with stent insertion, which data indicates to the nurse that the procedure was successful?
- A. Stone fragments are collected when straining the client's urine.
- B. Client denies urinary frequency, urgency, or dysuria.
- C. Urine is pale pink with no observable blood clots.
- D. Serum creatinine and blood urea nitrogen (BUN) levels are within normal limits.
Correct Answer: A
Rationale: Collecting stone fragments directly confirms the success of lithotripsy in breaking down the stone, unlike symptom relief or lab values.
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The nurse reviews discharge instructions with a client who has gastroesophageal reflux disease (GERD). Which instruction is most important for the nurse to emphasize?
- A. Minimize intake of spicy foods.
- B. Remain upright following meals.
- C. Avoid wearing tight fitting clothes.
- D. Begin a smoking cessation program.
Correct Answer: B
Rationale: Remaining upright after meals prevents acid reflux by facilitating digestion, making it the most critical instruction for GERD management.
The nurse is assessing a client who is newly diagnosed with hypothyroidism. Which assessment finding requires immediate intervention?
- A. Weight gain.
- B. Hypoventilation.
- C. Cold intolerance.
- D. Lethargy
Correct Answer: B
Rationale: Hypoventilation can lead to hypoxemia and hypercapnia, requiring immediate intervention to prevent respiratory crisis. Other symptoms are common but not immediately life-threatening.
A client with a large pleural effusion undergoes a thoracentesis. Following the procedure, which observation warrants immediate intervention by the nurse?
- A. The client's chest x-ray Indicates decreased pleural effusion.
- B. The client's arterial blood gas result is a pH 7.35, PaCO, 35 mm Hg, HCO,-26 mEq (26 mmol/L), PaO, 85 mm Hg.
- C. The client has asymmetrical chest wall expansion.
- D. The client reports pain at the insertion site.
Correct Answer: C
Rationale: Asymmetrical chest wall expansion may indicate pneumothorax, a serious complication requiring immediate intervention.
The nurse is collecting a urine specimen for a client with symptoms related to urethritis. Which collection method should the nurse implement?
- A. First voided specimen in the morning.
- B. A clean catch specimen.
- C. Any specimen voided after drinking adequate fluids.
- D. A 24-hour specimen.
Correct Answer: B
Rationale: A clean catch specimen minimizes contamination, providing accurate results for diagnosing urethritis, unlike other methods.
A client recovering from cardiac surgery experiences a dysrhythmia, noted on the telemetry monitor. Which assessment finding is most likely to have contributed to the development of the dysrhythmia?
- A. Calcium level 7.2 mg/dL (1.8 mmol/L).
- B. Potassium level 3.8 mg/dl. (3.8 mmol)
- C. Sodium level 140 mEq/L (140mmol/L).
- D. Oxygen saturation level 97%.
Correct Answer: A
Rationale: Hypocalcemia (low calcium) can cause cardiac dysrhythmias, such as prolonged QT intervals, unlike normal potassium, sodium, or oxygen levels.