When planning care for a client with right renal calculi, which nursing diagnosis has the highest
priority?
Acute pain related to movement of the stone.
Impaired urinary elimination related to obstructed flow of urine.
Risk for infection related to urinary stasis.
Deficient knowledge related to need for prevention of recurrence of calculi.
Rationale
The nursing diagnosis of the highest priority is "Acute pain related the the renal calculi's movement".
The nurse is caring for a client with non-Hodgkin’s lymphoma who is receiving chemotherapy.
Laboratory results reveal a platelet count of 10,000/ml. What action should the nurse implement?
Encourage fluids to 3000 ml/day.
Check stools for occult blood.
Provide oral hygiene every 2 hours.
Check for fever every 4 hours.
Rationale
Platelet counts less than 100,000/mm3 are indicative of thrombocytopenia, a common side effect of
chemotherapy. A client with thrombocytopenia should be assessed frequently for occult bleeding in
the emesis, sputum, feces, urine, nasogastric secretions, or wounds.
A client with acute osteomyelitis has undergone surgical debridement of the diseased bone and asks
the nurse how long will antibiotics have to be administered. Which information should the nurse
communicate?
Oral antibiotics for 2 to 4 months, then for dental procedure prophylaxis.
Parenteral antibiotics for 4 to 6 weeks, then oral antibiotics for up to 1 year.
Parenteral antibiotics for 4 to 8 weeks, then oral antibiotics for 4 to 8 weeks.
Parenteral antibiotics for 2 to 3 weeks, then oral antibiotics for 4 weeks.
Rationale
Treatment of acute osteomyelitis requires administration of high doses of parenteral antibiotics for 4
to 8 weeks, followed by oral antibiotics for another 4 to 8 weeks.
,The unlicensed assistive personnel (UAP) reports that an 87-year-old female client who is sitting in a
chair at the bedside has an oral temperature of 97.2 F ( 36.4 C). Which intervention should the nurse
implement?
Document the temperature reading on the vital sign graphic sheet.
Report the temperature to the healthcare provider immediately.
Instruct the UAP to take the client's temperature again in 30 minutes.
Advise the UAP to assist the client in returning to her bed.
Rationale
A subnormal temperature of 97.2 F (36.4 C) (orally) is a common finding in elderly clients, so the nurse
should document the findings and continue with the plan of care.
When teaching a client with breast cancer about the prescribed radiation therapy for treatment, what
information is important to include?
Dry, itchy skin changes may occur.
There is a possibility of long bone pain.
Permanent pigment changes to the breast may result.
A low-residue diet may be ordered to reduce the likelihood of diarrhea.
Rationale
Side effects from radiation to the breast most often include temporary skin changes such as: dryness,
tenderness, redness, swelling, and pruritis.
The nurse is assessing a middle-aged male client for risk factors related to chronic illness. Which
finding should the nurse assess further?
Thinning hair and dry scalp.
Increase in appetite and taste-bud acuity.
Increase in muscle tone but decreased muscle strength.
Increase in abdominal fat deposits.
Rationale
An increase in the abdominal girth is a risk factor for the development of metabolic syndrome.
According to the American Heart Association, men with a waist size 40 inches or larger and women 35
,inches or larger double their risk factor of developing CAD and increase their chances 5Xs of
developing DMII.
A female client with type 2 diabetes mellitus reports dysuria. Which assessment finding is most
important for the nurse to report to the healthcare provider?
Suprapublic pain and distention.
Bounding pulse at 100 beats/minute.
Fingerstick glucose of 300 mg/dl.
Small vesicular perineal lesions.
Rationale
Elevated fingerstick glucose levels needs to be reported tot he healthcare provider, so a plan of care
can be adjusted to treat the elevated glucose level. Also elevated glucose levels, spills into the urine
and provide a medium for bacterial growth.
A client with acute appendicitis is experiencing anxiety and loss of sleep about missing final
examination week at college. Which outcome is most important for the nurse to include in the plan of
care?
Sleeping six to eight hours.
Achieve a sense of control.
Utilize problem solving skills.
Increased focus of attention.
Rationale
The experience of psychological discomfort may be as real as physical pain for the client and should be
seen as a priority in care. Because the client is experiencing anxiety, achieving a sense of control is the
overall outcome of this client's nursing care plan.
A client with osteoarthritis requests information from the nurse about what type of exercise regimen
would be most beneficial for him. The nurse should communicate which information?
Low impact exercise, walking, swimming and water aerobics.
Repetitive strength-building exercises with weights or resistance bands.
Circuit training alternating with frequent rest periods.
, High-impact aerobic exercise.
Rationale
Low impact exercises such as walking or swimming, that do not put additional pressure and strain or
cause further harm to damaged joints, are most beneficial to clients with osteoarthritis. Strength-
building exercises, circuit training, and high-impact aerobics may cause too much stress on the joint
areas and subsequently increase inflammation and damage.
A male client with chronic atrial fibrillation and a slow ventricular response is scheduled for surgical
placement of a permanent pacemaker. The client asks the nurse how this device will help him. How
should the nurse explain the action of a synchronous pacemaker?
Ventricular irritability is prevented by the constant rate setting of pacemaker.
Ectopic stimulus in the atria is suppressed by the device usurping depolarization.
An impulse is fired every second to maintain a heart rate of 60 beats per minute.
An electrical stimulus is discharged when no ventricular response is sensed.
Rationale
The artificial cardiac pacemaker is an electronic device used to pace the heart when the normal
conduction pathway is damaged or diseased, such as a symptomatic dysrhythmias like atrial
fibrillation with a slow ventricular response. Pacing modes that are synchronous (impulse generated
on demand or as needed according to the patient's intrinsic rhythm) send an electrical signal from the
pacemaker to the wall of the myocardium stimulating it to contract when no ventricular depolarization
is sensed.
Which intervention should the nurse implement that best confirms placement of an endotracheal tube
(ETT)?
Use an end-tital CO2 detector.
Ascultate for bilateral breath sounds.
Obtain pulse oximeter reading.
Check symmetrical chest movement.
Rationale
The end-tidal carbon dioxide detector indicates the prescence of CO2tidalby a color change or a
number indicated on the detector, which is supporting evidence that the ETT is in the trachea, not the
esophagus.
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