Overall Score 79 out of 100 questions

Exam -3 Overall Score 79% out of 100 questions OluwaBusayo Ojo

10/18/2020

• The primary health care provider prescribes a 24-hour urine collection for vanillylmandelic

acid (VMA). The community health nurse visits the client at home and instructs the client in the procedure for the collection of the urine. Which statement, if made by the client, would indicate a need for further instruction?

Ans: "I can take medication if I need to during the collection."

Rational: Clients are reminded not to take medications for 2 to 3 days before a 24-hour urine collection for VMA. Because a 24-hour urine collection is a timed quantitative determination, it is essential that the client start the test with an empty bladder. Therefore, the client is instructed to void, discard the first urine, note the time, and start the test. The 24-hour urine specimen collection bottle must be kept on ice or refrigerated. For a VMA determination, the client is instructed to avoid tea, chocolate, vanilla, and all fruits for 2 days before urine collection begins.

• The nurse provides discharge instructions to a client after prostatectomy. What is the priority

discharge instruction for this client?

Ans: Increase fluid intake to at least 2.5 L/day.

Rational: A daily intake of 2.5 L of fluid should be maintained to limit clot formation and prevent infection. Driving a car and sitting for long periods are restricted for at least 3 weeks.The client should be instructed to avoid lifting objects heavier than 20 lb (9 kg) for at least 6 weeks. Passing small pieces of tissue or blood clots in the urine for up to 2 weeks after surgery is expected and does not necessitate contacting the PHCP.

• A client has returned to the nursing unit after a thyroidectomy. The nurse notes that the client

is complaining of tingling sensations around the mouth, fingers, and toes. On the basis of these findings, the nurse should next assess the results of which serum laboratory study?

Ans: Calcium

Rational: After surgery on the thyroid gland, the client may experience a temporary calcium imbalance. This is due to transient malfunction of the parathyroid glands. The nurse also would assess for Chvostek's and Trousseau's signs. The correct treatment is administration of calcium gluconate or calcium lactate. The remaining options are unrelated to the client's complaints. This study source was downloaded by 100000821716224 from CourseHero.com on 05-02-2021 07:24:42 GMT -05:00 https://www.coursehero.com/file/83212342/Saunders-NCLEX-Med-Surg-Corrections-3docx/ This study resource was shared via CourseHero.com

• The nurse is preparing to teach ostomy care to a client who has just had a urinary diversion;

the client expresses concern about body appearance. Which client action indicates that the best initial positive adaptation is being made?

Ans: Agrees to look at the ostomy

Rational: The best initial positive step in learning to care for an ostomy and to accept it as a part of the self is to be able to look at the ostomy. Once the client is able to look at the ostomy and touch it, the client can proceed more successfully to learn about ostomy care. The other options all indicate a deferral or refusal on the part of the client, which makes them less than optimal choices.

• A client with renal cell carcinoma of the left kidney is scheduled for nephrectomy. The right

kidney appears normal at this time. The client is anxious about whether dialysis will ultimately be needed. The nurse should plan to use which information in discussions with the client to alleviate anxiety?Ans: One kidney is adequate to meet the needs of the body as long as it has normal function.Rational: Fears about having only 1 functioning kidney are common in clients who must undergo nephrectomy for renal cancer. These clients need emotional support and reassurance that the remaining kidney should be able to fully meet the body's metabolic needs, as long as it has normal function. Therefore, the remaining options are incorrect.

• A male client has a tentative diagnosis of urethritis. The nurse should assess the client for

which manifestation of the disorder?

Ans: Dysuria and penile discharge

Rational: Urethritis in the male client often results from chlamydial infection and is characterized by dysuria, which is accompanied by a clear to mucopurulent discharge. Because this disorder often coexists with gonorrhea, diagnostic tests are done for both and include culture and rapid assays. Hematuria is not associated with urethritis. Pyuria is a condition where the urine contains white blood cells. Proteinuria is associated with kidney dysfunction.

• A client who is performing peritoneal dialysis at home calls the clinic and reports that the

outflow from the dialysis catheter seems to be decreasing in amount. The clinic nurse should ask which question first?

Ans: "Have you been constipated recently?"

Rational: Reduced outflow from the dialysis catheter may be caused by the catheter position, infection, or constipation. Constipation may contribute to a reduced outflow because peristalsis seems to aid in drainage. Options 1, 3, and 4 are unrelated to the causes of reduced outflow from the dialysis catheter.

• The nurse is creating a plan of care for a client with chronic kidney disease and uremia. The

nurse is developing interventions to assist in promoting an increased dietary intake while at the This study source was downloaded by 100000821716224 from CourseHero.com on 05-02-2021 07:24:42 GMT -05:00 https://www.coursehero.com/file/83212342/Saunders-NCLEX-Med-Surg-Corrections-3docx/ This study resource was shared via CourseHero.com

same time maintaining necessary dietary restrictions. Which action should the nurse include in the plan of care?

Ans: Maintain a diet high in calories with frequent snacks.

Rational: Uremia usually is accompanied by nausea, anorexia, and an unpleasant taste in the mouth. Most clients experience more nausea and vomiting in the morning. Therefore, to maintain optimal nutrition, it is best for these clients to eat a diet that is high in calories with frequent snacks and a light breakfast in the morning and larger meals later in the day. Dietary management usually is aimed at restricting protein, sodium, and potassium.

• A client who has a cold is seen in the emergency department with an inability to void. Because

the client has a history of benign prostatic hyperplasia, the nurse determines that the client should be questioned about the use of which medication?

Ans: Decongestants

Rational: In the client with benign prostatic hyperplasia, episodes of urinary retention can be triggered by certain medications, such as decongestants, anticholinergics, and antidepressants.These medications lessen the voluntary ability to contract the bladder. The client should be questioned about the use of these medications if he has urinary retention. Diuretics increase urine output. Antibiotics and antilipemics do not affect ability to urinate.

• A client tells the nurse about a pattern of a strong urge to void, followed by incontinence

before the client can get to the bathroom. Based on the data provided, which condition should the nurse suspect?

Ans: Urge incontinence

Rational: Urge incontinence occurs when the client experiences involuntary loss of urine soon after experiencing urgency. Total incontinence occurs when loss of urine is unpredictable and continuous. Stress incontinence occurs when the client voids in increments of less than 50 mL under conditions of increased abdominal pressure. Reflex incontinence occurs at rather predictable times that correspond to when a certain bladder volume is attained.

• The nurse is caring for a client who is scheduled to have a thyroidectomy and provides

instructions to the client about the surgical procedure. Which client statement indicates an understanding of the nurse's instructions?Ans: "I need to place my hands behind my neck when I have to cough or change positions." Rational: The client is taught that tension needs to be avoided on the suture line; otherwise hemorrhage may develop. One way of reducing incisional tension is to teach the client how to support the neck when coughing or being repositioned. Likewise, during the postoperative period the client should avoid any unnecessary movement of the neck. That is why sandbags and pillows frequently are used to support the head and neck. Any postoperative tingling in the fingers, toes, and lips probably is due to injury to the parathyroid gland during surgery, resulting in hypocalcemia. These signs and symptoms need to be reported immediately. Removal of the This study source was downloaded by 100000821716224 from CourseHero.com on 05-02-2021 07:24:42 GMT -05:00 https://www.coursehero.com/file/83212342/Saunders-NCLEX-Med-Surg-Corrections-3docx/ This study resource was shared via CourseHero.com

thyroid does not mean that the client will be taking antithyroid medications postoperatively.Thyroid replacement medications are necessary.

• A client has been diagnosed with hyperthyroidism. The nurse monitors for which signs and

symptoms indicating a complication of this disorder? Select all that apply.

Ans: Fever

Nausea Tremor Confusion Rational: Thyroid storm is an acute and life-threatening complication that occurs in a client with uncontrollable hyperthyroidism. Signs and symptoms of thyroid storm include elevated temperature (fever), nausea, and tremors. In addition, as the condition progresses, the client becomes confused. The client is restless and anxious and experiences tachycardia.

• The nurse is caring for a client just after ureterolithotomy and is monitoring the drainage

from the ureteral catheter hourly. Suddenly, the catheter stops draining. The nurse assesses the client and determines that which could be the cause of the problem? Select all that apply.

Ans: Blood clots

Mucous shreds Chemical sediment Catheter displacement Rational: After ureterolithotomy, a ureteral catheter is put in place. Urine flows freely through it for the first 2 to 3 days. As ureteral edema diminishes, urine leaks around the ureteral catheter and drains directly into the bladder. At this point, drainage through the ureteral catheter diminishes. Immediately after surgery, absence of drainage usually is caused by blockage from blood clots, mucous shreds, chemical sediment, or catheter displacement.

• A client with a diagnosis of addisonian crisis is being admitted to the intensive care unit.

Which findings will the interprofessional health care team focus on? Select all that apply.

Ans: Hypotension

Hyperkalemia Rational: In Addison's disease, also known as adrenal insufficiency, destruction of the adrenal gland leads to decreased production of adrenocortical hormones, including the glucocorticoid cortisol and the mineralocorticoid aldosterone. Addisonian crisis, also known as acute adrenal insufficiency, occurs when there is extreme physical or emotional stress and lack of sufficient adrenocortical hormones to manage the stressor. Addisonian crisis is a life-threatening emergency. One of the roles of endogenous cortisol is to enhance vascular tone and vascular This study source was downloaded by 100000821716224 from CourseHero.com on 05-02-2021 07:24:42 GMT -05:00 https://www.coursehero.com/file/83212342/Saunders-NCLEX-Med-Surg-Corrections-3docx/ This study resource was shared via CourseHero.com