Med Surge Success Test 2
The female client diagnosed with bladder cancer who has a cutaneous urinary diversion states, "Will I be able to have children now?" Which statement is the nurse's best response? 1. "Cancer does not make you sterile, but sometimes the therapy can." 2. "Are you concerned you can't have children?" 3. "You will be able to have as many children as you want." 4. "Let me have the chaplain come to talk with you about this."
1. "Cancer does not make you sterile, but sometimes the therapy can." Rationale:This client is asking for information and should be provided factual information. The surgery will not make the client sterile, but chemotherapy can induce menopause and radiation therapy to the pelvis can render a client sterile.
Which statement indicates the client diagnosed with calcium phosphate renal calculi understands the discharge teaching for ways to prevent future calculi formation? 1. "I should increase my fluid intake, especially in warm weather." 2. "I should eat foods containing cocoa and chocolate." 3. "I will walk about a mile every week and not exercise often." 4. "I should take one (1) vitamin a day with extra calcium."
1. "I should increase my fluid intake, especially in warm weather." Rationale: An increased fluid intake ensuring 2 to 3 L of urine a day prevents the stone-forming salts from becoming concentrated enough to precipitate.
The client is prescribed phenytoin (Dilantin), an anticonvulsant, for a seizure disorder. Which statement indicates the client understands the discharge teaching concerning this medication? 1. "I will brush my teeth after every meal." 2. "I will check my Dilantin level daily." 3. "My urine will turn orange while on Dilantin." 4. "I won't have any seizures while on this medication."
1. "I will brush my teeth after every meal." Rationale: Thorough oral hygiene after each meal, gum massage, daily flossing, and regular dental care are essential to prevent or control gingival hyperplasia, which is a common occurrence in clients taking Dilantin.
The nurse asks the male client with epilepsy if he has auras with his seizures. The client says, "I don't know what you mean. What are auras?" Which statement by the nurse would be the best response? 1. "Some people have a warning that the seizure is about to start." 2. "Auras occur when you are physically and psychologically exhausted." 3. "You're concerned that you do not have auras before your seizures?" 4. "Auras usually cause you to be sleepy after you have a seizure."
1. "Some people have a warning that the seizure is about to start" Rationale: An aura is a visual, auditory, or olfactory occurrence that takes place prior to a seizure and warns the client a seizure is about to occur. The aura often allows time for the client to lie down on the floor or find a safe place to have the seizure.
Which client would the nurse identify as being most at risk for experiencing a CVA? 1. A 55-year-old African American male. 2. An 84-year-old Japanese female. 3. A 67-year-old Caucasian male. 4. A 39-year-old pregnant female.
1. A 55 year old African American Male Rationale: African Americans have twice the rate of CVAs as Caucasians and men have a higher incidence than women; African Americans suffer more extensive damage from a CVA than do people of other cul- tural groups.
A client diagnosed with a subarachnoid hemorrhage has undergone a craniotomy for repair of a ruptured aneurysm. Which intervention will the intensive care nurse implement? 1. Administer a stool softener b.i.d. 2. Encourage the client to cough hourly. 3. Monitor neurological status every shift. 4. Maintain the dopamine drip to keep BP at 160/90.
1. Administer a stool softener BID Rationale: The client is at risk for increased intracranial pressure whenever performing the Valsalva maneuver, which will occur when straining during defecation. Therefore, stool softeners would be appropriate.
The client asks, "What does an elevated PSA test mean?" On which scientific rationale should the nurse base the response? 1. An elevated PSA can result from several different causes. 2. An elevated PSA can be only from prostate cancer. 3. An elevated PSA can be diagnostic for testicular cancer. 4. An elevated PSA is the only test used to diagnose BPH.
1. An elevated PSA can result from several different causes. Rationale: An elevated PSA can be from urinary retention, BPH, prostate cancer, or prostate infarct.
The client diagnosed with atrial fibrillation has experienced a transient ischemic attack (TIA). Which medication would the nurse anticipate being ordered for the client on discharge? 1. An oral anticoagulant medication. 2. A beta blocker medication. 3. An anti-hyperuricemic medication. 4. A thrombolytic medication.
1. An oral anticoagulant medication Rationale:The nurse would anticipate an oral anticoagulant, warfarin (Coumadin), to be prescribed to help prevent thrombi formation in the atria secondary to atrial fibrillation. The thrombi can become embolic and may cause a TIA or CVA (stroke). #2 is incorrect because Beta blockers slow the heart rate and decrease blood pressure but would not be an anticipated medication to help prevent a TIA secondary to atrial fibrillation.
The client returned from surgery after having a TURP and has a P 110, R 24, BP 90/40, and cool and clammy skin. Which interventions should the nurse implement? Select all that apply. 1. Assess the urine in the continuous irrigation drainage bag. 2. Decrease the irrigation fluid in the continuous irrigation catheter. 3. Lower the head of the bed while raising the foot of the bed. 4. Contact the surgeon to give an update on the client's condition. 5. Check the client's postoperative creatinine and BUN.
1. Assess the urine in the continuous irrigation drainage bag. 3. Lower the head of the bed while raising the foot of the bed. 4. Contact the surgeon to give an update on the client's condition. Rationale: 1. The nurse should assess the drainage. 3. The head of the bed should be lowered and the foot should be elevated to shunt blood to the central circulating system. 4. The surgeon needs to be notified of the change in condition. # 2 is incorrect because the patient is in shock, the nurse should increase irrigation to clear the red urine, not decrease the rate
The client diagnosed with renal calculi is scheduled for a 24-hour urine specimen collection. Which interventions should the nurse implement? Select all that apply. 1. Check for the ordered diet and medication modifications. 2. Instruct the client to urinate, and discard this urine when starting collection. 3. Collect all urine during 24 hours and place in appropriate specimen container. 4. Insert an indwelling catheter in client after having the client empty the bladder. 5. Instruct the UAP to notify the nurse when the client urinates.
1. Check for the ordered diet and medication modifications. 2. Instruct the client to urinate, and discard this urine when starting collection. 3. Collect all urine during 24 hours and place in appropriate specimen container. Rationale: 1. The health-care provider may order certain foods and medications when obtaining a 24-hour urine collection to evaluate for calcium oxalate or uric acid. 2.When the collection begins, the client should completely empty the bladder and discard this urine. The test is started after the bladder is empty. 3. All urine for 24 hours should be saved and put in a container with preservative, refrigerated, or placed on ice as indi- cated. Not following specific instructions will result in an inaccurate test result.
The occupational health nurse is concerned about preventing occupation-related acquired seizures. Which intervention should the nurse implement? 1. Ensure that helmets are worn in appropriate areas. 2. Implement daily exercise programs for the staff. 3. Provide healthy foods in the cafeteria. 4. Encourage employees to wear safety glasses.
1. Ensure the helmets are worn in appropriate areas. Rationale: Head injury is one of the main reasons for epilepsy that can be prevented through occupational safety precautions and highway safety programs.
The client with a continent urinary diversion is being discharged. Which discharge instructions should the nurse include in the teaching? 1. Have the client demonstrate catheterizing the stoma. 2. Instruct the client on how to pouch the stoma. 3. Explain the use of a bedside drainage bag at night. 4. Tell the client to call the HCP if the temperature is 99 ̊F or less.
1. Have the client demonstrate catheterizing the stoma Rationale: A continent urinary diversion is a surgical procedure in which a reservoir is created to hold urine until the client can self-catheterize the stoma. The nurse should observe the client's technique before discharge.
The client diagnosed with cancer of the bladder is undergoing intravesical chemotherapy. Which instruction should the nurse provide the client about the pretherapy routine? 1. Instruct the client to remain NPO after midnight before the procedure. 2. Explain the use of chemotherapy in bladder cancer. 3. Teach the client to administer Neupogen, a biologic response modifier. 4. Have the client take Tylenol, an analgesic, before coming to the clinic.
1. Instruct the client to remain NPO after midnight before the procedure. Rationale: The client will have medication instilled in the bladder which must remain in the bladder for a prescribed length of time. For this reason, the client must remain NPO before the procedure
The client has been newly diagnosed with epilepsy. Which discharge instructions should be taught to the client? Select all that apply. 1. Keep a record of seizure activity. 2. Take tub baths only; do not take showers. 3. Avoid over-the-counter medications. 4. Have anticonvulsant medication serum levels checked regularly. 5. Do not drive alone; have someone in the car.
1. Keep a record of seizure activity 3. Avoid over-the-counter medications 4. Have anticonvulsant medication serum levels checked regularly. Rationales: 1. Keeping a seizure and medication chart will be helpful when keeping follow-up appointments with the health-care provider and in identifying activities that may trigger a seizure. 3. Over-the-counter medications may contain ingredients that will interact with antiseizure medications or, in some cases, as with use of stimulants, possibly cause a seizure. 4. Most of the anticonvulsant medications have therapeutic serum levels that should be maintained, and regular checks of the serum levels help to ensure the correct level.
The nurse enters the room as the client is beginning to have a tonic-clonic seizure. What action should the nurse implement first? 1. Note the first thing the client does in the seizure. 2. Assess the size of the client's pupils. 3. Determine if the client is incontinent of urine or stool. 4. Provide the client with privacy during the seizure.
1. Note the first thing the client does post seizure Rationale: Noticing the first thing the client does during a seizure provides information and clues as to the location of the seizure in the brain. It is important to document whether the beginning of the seizure was observed.
The client diagnosed with a right-sided cerebrovascular accident is admitted to the rehabilitation unit. Which interventions should be included in the nursing care plan? Select all that apply. 1. Position the client to prevent shoulder adduction. 2. Turn and reposition the client every shift. 3. Encourage the client to move the affected side. 4. Perform quadriceps exercises three (3) times a day. 5. Instruct the client to hold the fingers in a fist.
1. Position the client to prevent shoulder adduction. 3. Encourage the client to move the affected side. Rationale: 1. Placing a small pillow under the shoulder will prevent the shoulder from adducting and causing a permanent conjecture. 3.The client should not ignore the paralyzed side, and the nurse must encourage the client to move it as much as possible; a written schedule may assist the client in exercising. Answers 2 & 4 are incorrect because: the body should be turned and repositioned every two hours, note every shift, quadricep exercises are recommended 5 times a day, not 3x.
The nurse is planning the care of a postoperative client with an ileal conduit. Which intervention should be included in the plan of care? 1. Provide meticulous skin care and pouching. 2. Apply sterile drainage bags daily. 3. Monitor the pH of the urine weekly. 4. Assess the stoma site every day.
1. Providing meticulous skin care & pouching Rationale: Urine is acidic, and the abdominal wall tissue is not designed to tolerate acidic environments. The stoma is pouched so urine will not touch the skin.
Which intervention should the nurse include when preparing a teaching plan for the client with chronic prostatitis? 1. Sit in a warm sitz bath for 10 to 20 minutes several times daily. 2. Sit in the chair with the feet elevated for two (2) hours daily. 3. Drink at least 3,000 mL of oral fluids, especially tea and coffee, daily. 4. Stop broad-spectrum antibiotics as soon as the symptoms subside.
1. Sit in a warm sitz bath for 10 to 20 minutes several times daily. Rationale: The client should sit in a warm sitz bath for 10 to 20 minutes several times each day to provide comfort and assist with healing.
Which information regarding the care of a cutaneous ileal conduit should the nurse discuss with the client? 1. Teach the client to instill a few drops of vinegar into the pouch. 2. Tell the client the stoma should be slightly dusky colored. 3. Inform the client large clumps of mucus are expected. 4. Tell the client it is normal for the urine to be pink or red in color.
1. Teach the client to instill a few drops of vinegar into the ouch Rationale: Vinegar will act as a deodorizing agent in the pouch and help prevent a strong urine smell.
Which statement indicates discharge teaching has been effective for the client who is postoperative TURP? 1. "I will call the surgeon if I experience any difficulty urinating." 2. "I will take my Proscar daily, the same as before my surgery." 3. "I will continue restricting my oral fluid intake." 4. "I will take my pain medication routinely even if I do not hurt."
1."I will call the surgeon if I experience any difficulty urinating." Rationale: This indicates that teaching is effective #2 is incorrect because Proscar is no longer needed post-surgery
The client diagnosed with renal calculi is admitted to the medical unit. Which intervention should the nurse implement first? 1. Monitor the client's urinary output. 2. Assess the client's pain and rule out complications. 3. Increase the client's oral fluid intake. 4. Use a safety gait belt when ambulating the client.
2. Assess the client's pain and rule out complications. Rationale: Assessment is the first part of the nursing process and is priority. The renal colic pain can be so intense it can cause a vasovagal response, with resulting hypotension and syncope.
The client is one (1) day postoperative TURP. Which task should the nurse delegate to the UAP? 1. Increase the irrigation fluid to clear clots from the tubing. 2. Elevate the scrotum on a towel roll for support. 3. Change the dressing on the first postoperative day. 4. Teach the client how to care for the continuous irrigation catheter.
2. Elevate the scrotum on the toilet roll for support Rationale:Elevating the scrotum on a towel for support is a task which can be delegated to the UAP.
The client diagnosed with cancer of the bladder is scheduled to have a cutaneous urinary diversion procedure. Which preoperative teaching intervention specific to the procedure should be included? 1. Demonstrate turn, cough, and deep breathing. 2. Explain a bag will drain the urine from now on. 3. Instruct the client on the use of a PCA pump. 4. Take the client to the ICU so the client can become familiar with it.
2. Explain a bag will drain the urine from now on Rationale:A urinary diversion procedure involves the removal of the bladder. In a cutaneous procedure, the ureters are implanted in some way to allow for stoma formation on the abdominal wall, and the urine drains into a pouch. There are numerous methods used for creating the stoma.
Which clinical manifestations should the nurse expect to assess for the client diagnosed with a ureteral renal stone? 1. Dull, aching flank pain and microscopic hematuria. 2. Nausea; vomiting; pallor; and cool, clammy skin. 3. Gross hematuria and dull suprapubic pain with voiding. 4. The client will be asymptomatic.
2. Nausea; vomiting; pallor; and cool, clammy skin. Rationale: The severe flank pain associated with a stone in the ureter often causes a sympathetic response with associated nausea; vomiting; pallor; and cool, clammy skin.
The nurse is assessing a client experiencing motor loss as a result of a left-sided cerebrovascular accident (CVA). Which clinical manifestations would the nurse document? 1. Hemiparesis of the client's left arm and apraxia. 2. Paralysis of the right side of the body and ataxia. 3. Homonymous hemianopsia and diplopia. 4. Impulsive behavior and hostility toward family.
2. Paralysis of the right side of the body & ataxia. Rationale:The most common motor dysfunction of a CVA is paralysis of one side of the body, hemiplegia; in this case with a left-sided CVA, the paralysis would affect the right side. Ataxia is the inability to coordinate movement.
The client is diagnosed with expressive aphasia. Which psychosocial client problem would the nurse include in the plan of care? 1. Potential for injury. 2. Powerlessness. 3. Disturbed thought processes. 4. Sexual dysfunction.
2. Powerlessness Rationale: Expressive aphasia means that the client cannot communicate thoughts but understands what is being communicated; this leads to frustration, anger, depression, and the inability to verbalize needs, which, in turn, causes the client to have a lack of control and feel powerless.
Which intervention is most important for the nurse to implement for the client diagnosed with rule-out renal calculi? 1. Assess the client's neurological status every two (2) hours. 2. Strain all urine and send any sediment to the laboratory. 3. Monitor the client's creatinine and BUN levels. 4. Take a 24-hour dietary recall during the client interview.
2. Strain all urine and send any sediment to the laboratory. Rationale: Passing a renal stone may negate the need for the client to have lithotripsy or a surgical procedure. Therefore, all urine must be strained, and a stone, if found, should be sent to the laboratory to determine what caused the stone.
The unlicensed assistive personnel (UAP) is attempting to put an oral airway in the mouth of a client having a tonic-clonic seizure. Which action should the primary nurse take? 1. Help the UAP to insert the oral airway in the mouth. 2. Tell the UAP to stop trying to insert anything in the mouth. 3. Take no action because the UAP is handling the situation. 4. Notify the charge nurse of the situation immediately.
2. Tell the UAP to stop trying to insert anything in the mouth. Rationale: The nurse should tell the UAP to stop trying to insert anything in the mouth of the client experiencing a seizure. Broken teeth and injury to the lips and tongue may result from trying to place anything in the clenched jaws of a client having a tonic-clonic seizure.
The nurse is caring for a client with a TURP. Which expected outcome indicates the client's condition is improving? 1. The client is using the maximum amount allowed by the PCA pump. 2. The client's bladder spasms are relieved by medication. 3. The client's scrotum is swollen and tender with movement. 4. The client has passed a large, hard, brown stool this morning.
2. The client's bladder spasms are relieved by medication Rationale: Bladder spasms are common, but being relieved with medication indicates the condition is improving.
The male client diagnosed with metastatic cancer of the bladder is emaciated and refuses to eat. Which nursing action is an example of the ethical principle of paternalism? 1. The nurse allows the client to talk about not wanting to eat. 2. The nurse tells the client if he does not eat, a feeding tube will be placed. 3. The nurse consults the dietitian about the client's nutritional needs. 4. The nurse asks the family to bring favorite foods for the client to eat.
2. The nurse tells the client if he does not eat, a feeding tube will be placed. Rationale: Paternalism is deciding for the client what is best, similar to a parent making decisions for a child. Feeding a client, as with a feeding tube, without the client wishing to eat is paternalism.
The nurse observes red urine and several large clots in the tubing of the normal saline continuous irrigation catheter for the client who is one (1) day postoperative TURP. Which intervention should the nurse implement? 1. Remove the indwelling catheter. 2. Titrate the NS irrigation to run faster. 3. Administer protamine sulfate IVP. 4. Administer vitamin K slowly.
2. Titrate the NS irrigation to run faster. Rationale: Increasing the irrigation fluid will flush out the clots and blood.
Which statement by the female client indicates that the client understands factors that may precipitate seizure activity? 1. "It is all right for me to drink coffee for breakfast." 2. "My menstrual cycle will not affect my seizure disorder." 3. "I am going to take a class in stress management." 4. "I should wear dark glasses when I am out in the sun."
3. " I am going to take a class in stress management" Rationale: Tension states, such as anxiety and frustration, induce seizures in some clients, so stress management may be helpful in preventing seizures.
The client diagnosed with cancer of the bladder states, "I have young children. I am too young to die." Which statement is the nurse's best response? 1. "This cancer is treatable and you should not give up." 2. "Cancer occurs at any age. It is just one of those things." 3. "You are afraid of dying and what will happen to your children." 4. "Have you talked to your children about your dying?"
3. "You are afraid of dying and what will happen to your children." Rationale: This is an example of restating, a therapeutic technique used to clarify the client's feelings and encourage a discussion of those feelings.
Which assessment data would indicate to the nurse that the client would be at risk for a hemorrhagic stroke? 1. A blood glucose level of 480 mg/dL. 2. A right-sided carotid bruit. 3. A blood pressure of 220/120 mm Hg. 4. The presence of bronchogenic carcinoma.
3. A blood pressure of 220/120 mm Hg Rationale: Uncontrolled hypertension is a risk factor for hemorrhagic stroke, which is a ruptured blood vessel inside the cranium. #1 is incorrect because: This glucose level is elevated and could predispose the client to ischemic neurologi- cal changes due to blood viscosity, but it is not a risk factor for a hemorrhagic stroke.
The client is admitted to the intensive care department (ICD) experiencing status epilepticus. Which collaborative intervention should the nurse anticipate? 1. Assess the client's neurological status every hour. 2. Monitor the client's heart rhythm via telemetry. 3. Administer an anticonvulsant medication by intravenous push. 4. Prepare to administer a glucocorticosteroid orally.
3. Administer an anticonvulsant medication IV push. Rationale: Administering an anticonvulsant medication by intravenous push requires the nurse to have an order or confer with another member of the health-care team.
The client diagnosed with renal calculi is scheduled for lithotripsy. Which postprocedure nursing task is the most appropriate to delegate to the UAP? 1. Monitor the amount, color, and consistency of urine output. 2. Teach the client about care of the indwelling Foley catheter. 3. Assist the client to the car when being discharged home. 4. Take the client's postprocedural vital signs.
3. Assist the client to the car when being discharged home. Rationale: The UAP could assist the client to the car once the discharge has been completed.
The nurse educator is presenting an in-service on seizures. Which disease process is the leading cause of seizures in the elderly? 1. Alzheimer's disease. 2. Parkinson's disease. 3. Cerebral vascular accident (stroke). 4. Brain atrophy due to aging.
3. Cerebral Vascular Accident (Stroke) Rationale: A CVA (stroke) is the leading cause of seizures in the elderly; increased intracranial pressure associated with the stroke can lead to seizures.
Which modifiable risk factor should the nurse identify for the development of cancer of the bladder in a client? 1. Previous exposure to chemicals. 2. Pelvic radiation therapy. 3. Cigarette smoking. 4. Parasitic infections of the bladder.
3. Cigarette Smoking Rationale: Cigarette smoke contains more than 400 chemicals, 17 of which are known to cause cancer. The risk is directly proportional to the amount of smoking.
The client with a history of renal calculi calls the clinic and reports having burning on urination, chills, and an elevated temperature. Which instruction should the nurse discuss with the client? 1. Increase water intake for the next 24 hours. 2. Take two (2) Tylenol to help decrease the temperature. 3. Come to the clinic and provide a urinalysis specimen. 4. Use a sterile 4 × 4 gauze to strain the client's urine.
3. Come to the clinic and provide a urinalysis specimen. Rationale: A urinalysis can assess for hematuria, the presence of white blood cells, crystal fragments, or all three, which can determine if the client has a urinary tract infection or possibly a renal stone, with accompanying signs/symptoms of UTI.
The laboratory data reveal a calcium phosphate renal stone for a client diagnosed with renal calculi. Which discharge teaching intervention should the nurse implement? 1. Encourage the client to eat a low-purine diet and limit foods such as organ meats. 2. Explain the importance of not drinking water two (2) hours before bedtime. 3. Discuss the importance of limiting vitamin D-enriched foods. 4. Prepare the client for extracorporeal shock wave lithotripsy (ESWL).
3. Discuss the importance of limiting vitamin D-enriched foods. Rationale: Dietary changes for preventing renal stones include reducing the intake of the primary substance forming the calculi. In this case, limiting vitamin D will inhibit the absorption of calcium from the gastrointestinal tract.
The client is scheduled for an electroencephalogram (EEG) to help diagnose a seizure disorder. Which preprocedure teaching should the nurse implement? 1. Tell the client to take any routine antiseizure medication prior to the EEG. 2. Tell the client not to eat anything for eight (8) hours prior to the procedure. 3. Instruct the client to stay awake for 24 hours prior to the EEG. 4. Explain to the client that there will be some discomfort during the procedure.
3. Instruct the client to stay awake 24 hours prior to EEG Rationale: The goal is for the client to have a seizure during the EEG. Sleep deprivation, hyperventilating, or flashing lights may induce a seizure.
The client who is postoperative TURP asks the nurse, "When will I know if I will be able to have sex after my TURP?" Which response is most appropriate by the nurse? 1. "You seem anxious about your surgery." 2. "Tell me about your fears of impotency." 3. "Potency can return in six (6) to eight (8) weeks." 4. "Did you ask your doctor about your concern?"
3. Potency can return 6 to 8 weeks. Rationale: This is usually the length of time clients need to wait prior to having sexual intercourse; this is the information the client wants to know.
A 78-year-old client is admitted to the emergency department with numbness and weakness of the left arm and slurred speech. Which nursing intervention is priority? 1. Prepare to administer recombinant tissue plasminogen activator (rt-PA). 2. Discuss the precipitating factors that caused the symptoms. 3. Schedule for a STAT computed tomography (CT) scan of the head. 4. Notify the speech pathologist for an emergency consult.
3. Schedule a STAT computed topography (CT) scan of the head Rationale: A CT scan will determine if the client is having a stroke or has a brain tumor or another neurological disorder. If a CVA is diagnosed, the CT scan can determine if it is a hemorrhagic or ischemic accident and guide treatment.
The nurse and an unlicensed assistive personnel (UAP) are caring for a client with right-sided paralysis. Which action by the UAP requires the nurse to intervene? 1. The assistant places a gait belt around the client's waist prior to ambulating. 2. The assistant places the client on the back with the client's head to the side. 3. The assistant places a hand under the client's right axilla to move up in bed. 4. The assistant praises the client for attempting to perform ADLs independently.
3. The assistant places a hand under the client's right axilla to move up in bed. Rationale: This action is inappropriate and would require intervention by the nurse because pulling on a flaccid shoulder joint could cause shoulder dislocation; the client should be pulled up by placing the arm underneath the back or using a lift sheet.
The client who just had a three (3)-minute seizure has no apparent injuries and is oriented to name, place, and time but is very lethargic and just wants to sleep. Which intervention should the nurse implement? 1. Perform a complete neurological assessment. 2. Awaken the client every 30 minutes. 3. Turn the client to the side and allow the client to sleep. 4. Interview the client to find out what caused the seizure.
3. Turn the client to the side and allow for the client to sleep. Rationale: During the postictal (after-seizure) phase, the client is very tired and should be allowed to rest quietly; placing the client on the side will help prevent aspiration and maintain a patent airway.
The client is diagnosed with a uric acid stone. Which foods should the client eliminate from the diet to help prevent reoccurrence? 1. Beer and colas. 2. Asparagus and cabbage. 3. Venison and sardines. 4. Cheese and eggs.
3. Venison & Sardines Rationale: Venison, sardines, goose, organ meats, and herring are high-purine foods, which should be eliminated from the diet to help prevent uric acid stones.
The client had surgery to remove a kidney stone. Which laboratory assessment data warrant immediate intervention by the nurse? 1. A serum potassium level of 3.8 mEq/L. 2. A urinalysis shows microscopic hematuria. 3. A creatinine level of 0.8 mg/100 mL. 4. A white blood cell count of 14,000/mm3.
4. A white blood cell count of 14,000/mm3. Rationale:The white blood cell count is elevated; normal is 5,000 to 10,000/mm3.
The client is diagnosed with an acute episode of ureteral calculi. Which client problem is priority when caring for this client? 1. Fluid volume loss. 2. Knowledge deficit. 3. Impaired urinary elimination. 4. Alteration in comfort.
4. Alteration in comfort. Rationale: Pain is priority. The pain can be so severe a sympathetic response may occur, causing nausea; vomiting; pallor; and cool, clammy skin.
The client with a TURP who has a continuous irrigation catheter complains of the need to urinate. Which intervention should the nurse implement first? 1. Call the surgeon to inform the HCP of the client's complaint. 2. Administer the client a narcotic medication for pain. 3. Explain to the client this sensation happens frequently. 4. Assess the continuous irrigation catheter for patency.
4. Assess the continuous irrigation catheter for patency. Rationale:The nurse should always assess any complaint before dismissing it as a commonly occurring problem.
The nurse and a licensed practical nurse (LPN) are caring for a group of clients. Which intervention should be assigned to the LPN? 1. Assessment of the client who has had a Kock pouch procedure. 2. Monitoring of the postop client with a WBC of 22,000/mm3. 3. Administration of the prescribed antineoplastic medications. 4. Care for the client going for an MRI of the kidneys.
4. Care for the client going for an MRI of kidneys Rationale:4. It is in the scope of practice for the LPN to care for this client.
The 85-year-old client diagnosed with a stroke is complaining of a severe headache. Which intervention should the nurse implement first? 1. Administer a nonnarcotic analgesic. 2. Prepare for STAT magnetic resonance imaging (MRI). 3. Start an intravenous infusion with D5W at 100 mL/hr. 4. Complete a neurological assessment.
4. Complete a neurological assessment. Rationale: The nurse must complete a neurological assessment to help determine the cause of the headache before taking any further action. *Assessment is always first!
The male client is sitting in the chair and his entire body is rigid with his arms and legs contracting and relaxing. The client is not aware of what is going on and is making guttural sounds. Which action should the nurse implement first? 1. Push aside any furniture. 2. Place the client on his side. 3. Assess the client's vital signs. 4. Ease the client to the floor.
4. Ease the client to the floor Rationale: The client should not remain in the chair during a seizure. He should be brought safely to the floor so that he will have room to move the extremities. Although pushing aside furniture is important, it is not the first priority
The client with possible renal calculi is scheduled for a renal ultrasound. Which intervention should the nurse implement for this procedure? 1. Ask if the client is allergic to shellfish or iodine. 2. Keep the client NPO eight (8) hours prior to the ultrasound. 3. Ensure the client has a signed informed consent form. 4. Explain the test is noninvasive and there is no discomfort.
4. Explain the test is noninvasive and there is no discomfort. Rationale: No special preparation is needed for this noninvasive, nonpainful test. A conductive gel is applied to the back or flank and then a transducer is applied which produces sound waves, resulting in a picture.
The client has been diagnosed with a cerebrovascular accident (stroke). The client's wife is concerned about her husband's generalized weakness. Which home modification should the nurse suggest to the wife prior to discharge? 1. Obtain a rubber mat to place under the dinner plate. 2. Purchase a long-handled bath sponge for showering. 3. Purchase clothes with Velcro closure devices. 4. Obtain a raised toilet seat for the client's bathroom.
4. Obtain a raised toilet seat for the client's bathroom. Rationale: Raising the toilet seat is modifying the home and addresses the client's weakness in being able to sit down and get up without straining muscles or requiring lifting assistance from the wife.
Which nursing diagnosis is priority for the client who has undergone a TURP? 1. Potential for sexual dysfunction. 2. Potential for an altered body image. 3. Potential for chronic infection. 4. Potential for hemorrhage.
4. Potential for hemorrhage Rationale: This is a potentially life-threatening problem.
The nurse is planning care for a client experiencing agnosia secondary to a cerebrovas- cular accident. Which collaborative intervention will be included in the plan of care? 1. Observe the client swallowing for possible aspiration. 2. Position the client in a semi-Fowler's position when sleeping. 3. Place a suction setup at the client's bedside during meals. 4. Refer the client to an occupational therapist for evaluation.
4. Refer the client to occupational therapist for evaluation Rationale: A collaborative intervention is an intervention in which another health-care discipline—in this case, occupational therapy—is used in the care of the client.
Which data support to the nurse the client's diagnosis of acute bacterial prostatitis? 1. Terminal dribbling. 2. Urinary frequency. 3. Stress incontinence. 4. Sudden fever and chills.
4. Sudden fever & chills Rationale: Clients with acute bacterial prostatitis will frequently experience a sudden onset of fever and chills. Clients with chronic prostatitis have milder symptoms.
The client is two (2) days post-ureterosigmoidostomy for cancer of the bladder. Which assessment data warrant notification of the HCP by the nurse? 1. The client complains of pain at a "3," 30 minutes after being medicated. 2. The client complains it hurts to cough and deep breathe. 3. The client ambulates to the end of the hall and back before lunch. 4. The client is lying in a fetal position and has a rigid abdomen.
4. The client is lying in a fetal position nd has a rigid abdomen Rationale: The client is drawn up in a position which relieves pressure off the abdomen; a rigid abdomen is an indicator of peritonitis, a medical emergency.
The nurse is caring for clients on a renal surgery unit. After the afternoon report, which client should the nurse assess first? 1. The male client who just returned from a CT scan who states he left his glasses in the x-ray department. 2. The client who is one (1) day postoperative and has a moderate amount of serous drainage on the dressing. 3. The client who is scheduled for surgery in the morning and wants an explanation of the operative procedure before signing the permit. 4. The client who had ileal conduit surgery this morning and has not had any drainage in the drainage bag.
4. The client who had an ileal conduit surgery this morning and has not had any drainage in the drainage bag. Rationale: An ileal conduit is a procedure diverting urine from the bladder and provides an alternate cutaneous pathway for urine to exit the body. Urinary output should always be at least 30 mL/hr. This client should be assessed to make sure the stents placed in the ureters have not become dislodged or blocked.
