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A 27-year-old male patient was admitted with severe left flank pain. After a confirmation of a
renal calculi, what would be the most appropriate nursing interventions. Select all that apply.
a. Administer prescribed analgesics
b. Administer a low-fat diet.
c. Promote increased fluid intake
d. Position patient in Trendelenburg position.
e. Strain all urine output
A, C, E
Which of the following nursing actions is most important in caring for the client following
lithotripsy?
a. Strain the urine carefully for stone fragments.
b. Notify the physician of hematuria.
c. Monitor the continuous bladder irrigation.
d. Administer allopurinol (Zyloprim).
A
A client had a transurethral prostatectomy for benign prostatic hypertrophy. He's currently
being treated with a continuous bladder irrigation and is complaining of an increase in severity
of bladder spasms. Which of the interventions should be done first?
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,a. Check for the presence of clots, and make sure the catheter is draining properly
b. Stop the irrigation and call the physician
c. Administer a belladonna and opium suppository as ordered by the physician.
d. Administer an oral analgesic
A
A nurse is completing the admission assessment of a client who has a kidney stone. Select all
that the nurse would expect to find.
a. Tachycardia
b. CVA tenderness/pain
c. Bradypnea
d. Hematuria
e. Polyuria
A, B, D
Which of the following are NOT typical signs/symptoms of right-sided heart failure? Select all
that apply.
a. Jugular venous distention
b. Persistent cough
c. Weight gain
d. Crackles
e. Nocturia
f. Orthopnea
B, D, F
An 82-year-old male patient is receiving continuous bladder irrigation with 0.45% NaCl. 1200ml
have been instilled, a total output of 1500ml is collected in the Foley catheter collection bag.
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,What would be the true urine output?
a. 2700 ml
b. 300 ml
c. 1500 ml
d. 1200 m
B
The nurse is collecting data from a client. Which symptom described by the client is
characteristic of an early symptom of BPH.
a. Occasional constipation
b. Scrotal edema
c. Decreased force in the stream of urine
d. Nocturia
C
The client's underlying heart rhythm is sinus rhythm, but the rhythm is irregular because of
occasional early beats. The configuration of the P waves is normal, except the P wave of the
early beat does not look the same as the others. The morphology of the QRS complex is the
same for all beats. The heart rate is 66 beats per min, and the blood pressure is normal. How
should the nurse interpret this finding?
a. Sinus tachycardia
b. Normal sinus rhythm
c. Sinus rhythm with premature atrial contractions (PACs)
d. Sinus bradycardia with premature ventricular contractions (PVCs)
C
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, Which assessment data would the nurse recognize to support the diagnoses of abdominal aortic
aneurysm (AAA)?
a. Ripping abdominal pain
b. Decreased urinary output
c. Shortness of breath
d. Abdominal bruit
D
A patient presents with shortness of breath, non-pitting edema of lower extremities, and
distended neck veins. Past medical history includes hyperlipidemia and asthma. What are
appropriate nursing actions? Select all the apply.
a. Assess medication regimen for asthma
b. Check peripheral pulses
c. Administer Oxygen
d. Administer Nitroglycerine
e. Restrict fluid and sodium
B, C, E
A patient was diagnosed with oxalate renal calculi. When planning this patient's health
education, what nutritional guidelines should the nurse provide?
A. Restrict protein intake as ordered.
B. Increase intake of potassium-rich foods.
C. Follow a low-calcium diet.
D. Encourage intake of food containing oxalates.
A
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