1. a nurse is assessing a client who
had extracorporeal shock wake lithotripsy (ESWL) 6 hr ago. which of the
following findings should the nurse expect?
ANS: stone fragments in the urine
RATIONALE: ESWL
is an effort to break the calculi so that the fragments pass down the ureter,
into the bladder, and through the urethra during voiding. Following the
procedure, the nurse should strain the client's urine to confirm the passage of
stones.
2. a nurse is assessing a group of
clients for indications of role changes. the nurse should identify that which
of the following clients is at risk for experiencing a role change?
ANS: a client who has multiple sclerosis and is
experiencing progressive difficulty ambulating.
RATIONALE: The
nurse should identify that progression of a neurologic disease such as multiple
sclerosis can lead to a role change as the client becomes less independent.
3. a nurse is caring for a client who
has a new diagnosis of hyperthyroidism. which of the following is the priority
assessment finding that the nurse should report to the provider?
ANS: blood pressure 170/80 mm Hg
RATIONALE: Using
the urgent vs. nonurgent approach to client care, the nurse should determine
that the priority finding is a systolic blood pressure of 170 mm Hg, which indicates
that the client is at risk for thyroid storm.
4. a nurse is providing discharge
instructions to a client who has a partial-thickness burn on the hand. which of
the following instructions should the nurse include?
ANS: wrap fingers with individual dressings.
RATIONALE: The
nurse should instruct the client to wrap the fingers individually to allow for
functional use of the hand while healing occurs. The nurse should also instruct
the client to perform range-of-motion exercises to each finger every hour while
awake to promote function of the injured hand.
5. a nurse is providing teaching to a
client who is receiving chemotherapy and has a new prescription for epoetin
alfa. which of the following client statements indicates an understanding of
the teaching?
ANS: I will monitor my blood pressure while
taking this medication
6. a nurse is providing discharge
teaching to a client who has heart failure and a new prescription for a
potassium-sparing diuretic. which of the following information should the nurse
include in the teaching?
ANS: try to walk at least three times per week for
exercise.
RATIONALE: The development of a regular exercise
routine can improve outcomes in clients who have heart failure.
Category | ATI |
Release date | 2021-09-08 |
Pages | 28 |
Language | English |
Comments | 0 |
Sales | 0 |
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