QUESTIONS WITH SOLUTIONS GRADED A+
◉ A nurse is reviewing the urinalysis results of a client who has
completed a 14-day course of ciprofloxacin to treat pyelonephritis.
Which of the following values should indicate to the nurse that the
client has a continuing infection?
Negative nitrites
RBCs < 2
Positive leukocyte esterase
Amber-colored urine Answer: Positive leukocyte esterase
The nurse should identify that a positive leukocyte esterase test is an
indication of the presence of WBCs in the urine and the presence of
continued infection.
◉ A nurse is assessing a client for manifestations of grief after
having a colostomy for removal of colon cancer. Which of the
,following findings indicates to the nurse that the client has accepted
the loss?
Becomes angry when it is time to perform colostomy care
Touches the colostomy stoma when the bag is changed
Looks away as the nurse empties the colostomy bag
Tells others that it will be nice to have a normal bowel movement
again Answer: Touches the colostomy stoma when the bag is
changed
The client touching the colostomy stoma when the bag is changed
should indicate to the nurse that the client is accepting and coping
with the alteration of body image and has gone through the stages of
grief.
◉ A nurse is assessing a school-age child who has appendicitis with
possible perforation. Which of the following findings should the
nurse identify as a manifestation of peritonitis?
Abdominal distention
,Bradycardia
Hyperactive bowel sounds
Slow, deep breathing Answer: Abdominal distention
The nurse should identify that peritonitis is an inflammation of the
lining of the abdominal wall. This inflammation, along with the ileus
that develops, causes abdominal distention; therefore, the nurse
should identify this as a manifestation of peritonitis.
◉ A nurse is reviewing the medical record of a client who has a
peptic ulcer. Which of the following findings is a priority to report to
the provider?
Melena stools
Hemoglobin 7.6 mg/dL
Weight gain of 1.4 kg (3 lb) in 2 weeks
Dyspepsia during the day Answer: Hemoglobin 7.6 mg/dL
, When using the urgent vs. nonurgent approach to client care, the
nurse should determine that the priority finding to report to the
provider is the hemoglobin below the expected reference range,
which in an indication of a peptic ulcer that is chronically bleeding.
◉ A nurse in an emergency department is assessing a client who has
hyperthermia. Which of the following findings should the nurse
identify as an indication that the client has heat exhaustion?
Hallucinations
Vomiting
Bradycardia
Seizures Answer: Vomiting
The nurse should identify that heat exhaustion is usually the result
of excess sweating, leading to dehydration. Manifestations include
nausea, vomiting, headache, dizziness, fainting, and a temperature
typically between 38.3º C and 38.9º C (101º F and 102º F).
◉ A nurse is providing teaching to a client who is experiencing
malabsorption related to lactose intolerance. Which of the following