Health and Healing IV Questions With Complete Solutions
A 70-kg postoperative client has an average urine output of 25
mL/hr during the first 8 hours. Given this assessment, what
would the priority nursing intervention(s) be?
a. Perform a straight catheterization to measure the amount of
urine in the bladder.
b. Notify the physician and anticipate obtaining blood work to
evaluate renal function.
c. Continue to monitor the client because this is a normal finding
during this time period.
d. Evaluate the client's fluid volume status since surgery and
obtain a bladder ultrasound. Correct Answers D
A client has had a cystectomy and ileal conduit diversion
performed. Four days postoperatively, mucous shreds are seen in
the drainage bag. Which action should the nurse undertake?
a. Notify the health care provider.
b. Notify the charge nurse.
c. Irrigate the drainage tube.
d. Chart it as a normal observation. Correct Answers D
A client has recently received a diagnosis of early-stage breast
cancer. Which of the following is most appropriate for the nurse
to focus on?
,a. Maintaining the client's hope
b. Preparing a will and advance directives
c. Discussing replacement child care for client's children
d. Discussing the client's past experiences with her
grandmother's cancer Correct Answers A
A client is admitted to the hospital with severe renal colic
caused by renal lithiasis. What is the nurse's first priority in
management of the client?
a. To administer opioids as prescribed
b. To obtain supplies for straining all urine
c. To encourage fluid intake of 3 to 4 L/day
d. To keep the client on nothing-by-mouth status in preparation
for surgery Correct Answers A
A client is admitted to the PACU after major abdominal surgery.
During the initial assessment, the client states, "I am going to
throw up." What would be the priority nursing intervention?
a. Increase the rate of the IV fluids.
b. Obtain vital signs, including O2 saturation.
c. Position client in lateral recovery position.
d. Administer antiemetic medication as ordered. Correct
Answers C
,A client is concerned that he may have asthma. Of the following
symptoms that he relates to the nurse, which ones suggest
asthma or risk factors for asthma? (Select all that apply.)
a. Allergic rhinitis
b. Prolonged inhalation
c. History of skin allergies
d. Cough, especially at night
e. Gastric reflux or heartburn Correct Answers A
C
D
E
A client who has an opioid use disorder is scheduled for surgery
following an automobile accident. What is important for the
nurse to recognize in this case?
a. The client may need less pain medication during the
postoperative period.
b. The client should be continued on any opioid agonist therapy
(e.g., methadone) throughout the perioperative period.
c. The client may have an immediate onset of withdrawal
symptoms when given anaesthetic and analgesic agents.
d. The client has a low risk for physical withdrawal symptoms
but is likely to experience craving during the postoperative
period. Correct Answers B
, A client with a ureterolithotomy returns from surgery with a
nephrostomy tube in place. What is the priority nursing action
related to caring for this client?
a. Encouraging the client to drink fruit juices and milk
b. Encouraging intake of fluids of at least 2 to 3 L/day after
nausea has subsided
c. Notifying the health care provider if nephrostomy tube
drainage is more than 30 mL/hr
d. Irrigating the nephrostomy tube with 10 mL of normal saline
solution as needed Correct Answers B
A nurse believes that clients with the same type of tissue injury
should have the same amount of pain. Which of the following
statements best describes this belief?
a. It will contribute to appropriate pain management.
b. It is an accurate statement about pain mechanisms and an
expected goal of pain therapy.
c. The nurse's belief will have no effect on the type of care
provided to people in pain.
d. It is a common misconception about pain and a major
contributor to ineffective pain management. Correct Answers D
A 70-kg postoperative client has an average urine output of 25
mL/hr during the first 8 hours. Given this assessment, what
would the priority nursing intervention(s) be?
a. Perform a straight catheterization to measure the amount of
urine in the bladder.
b. Notify the physician and anticipate obtaining blood work to
evaluate renal function.
c. Continue to monitor the client because this is a normal finding
during this time period.
d. Evaluate the client's fluid volume status since surgery and
obtain a bladder ultrasound. Correct Answers D
A client has had a cystectomy and ileal conduit diversion
performed. Four days postoperatively, mucous shreds are seen in
the drainage bag. Which action should the nurse undertake?
a. Notify the health care provider.
b. Notify the charge nurse.
c. Irrigate the drainage tube.
d. Chart it as a normal observation. Correct Answers D
A client has recently received a diagnosis of early-stage breast
cancer. Which of the following is most appropriate for the nurse
to focus on?
,a. Maintaining the client's hope
b. Preparing a will and advance directives
c. Discussing replacement child care for client's children
d. Discussing the client's past experiences with her
grandmother's cancer Correct Answers A
A client is admitted to the hospital with severe renal colic
caused by renal lithiasis. What is the nurse's first priority in
management of the client?
a. To administer opioids as prescribed
b. To obtain supplies for straining all urine
c. To encourage fluid intake of 3 to 4 L/day
d. To keep the client on nothing-by-mouth status in preparation
for surgery Correct Answers A
A client is admitted to the PACU after major abdominal surgery.
During the initial assessment, the client states, "I am going to
throw up." What would be the priority nursing intervention?
a. Increase the rate of the IV fluids.
b. Obtain vital signs, including O2 saturation.
c. Position client in lateral recovery position.
d. Administer antiemetic medication as ordered. Correct
Answers C
,A client is concerned that he may have asthma. Of the following
symptoms that he relates to the nurse, which ones suggest
asthma or risk factors for asthma? (Select all that apply.)
a. Allergic rhinitis
b. Prolonged inhalation
c. History of skin allergies
d. Cough, especially at night
e. Gastric reflux or heartburn Correct Answers A
C
D
E
A client who has an opioid use disorder is scheduled for surgery
following an automobile accident. What is important for the
nurse to recognize in this case?
a. The client may need less pain medication during the
postoperative period.
b. The client should be continued on any opioid agonist therapy
(e.g., methadone) throughout the perioperative period.
c. The client may have an immediate onset of withdrawal
symptoms when given anaesthetic and analgesic agents.
d. The client has a low risk for physical withdrawal symptoms
but is likely to experience craving during the postoperative
period. Correct Answers B
, A client with a ureterolithotomy returns from surgery with a
nephrostomy tube in place. What is the priority nursing action
related to caring for this client?
a. Encouraging the client to drink fruit juices and milk
b. Encouraging intake of fluids of at least 2 to 3 L/day after
nausea has subsided
c. Notifying the health care provider if nephrostomy tube
drainage is more than 30 mL/hr
d. Irrigating the nephrostomy tube with 10 mL of normal saline
solution as needed Correct Answers B
A nurse believes that clients with the same type of tissue injury
should have the same amount of pain. Which of the following
statements best describes this belief?
a. It will contribute to appropriate pain management.
b. It is an accurate statement about pain mechanisms and an
expected goal of pain therapy.
c. The nurse's belief will have no effect on the type of care
provided to people in pain.
d. It is a common misconception about pain and a major
contributor to ineffective pain management. Correct Answers D
