1. A nurse is planning care for a client who has renal calculi. Which of
the following interventions should the nurse include to promote
elimination of the calculi?
Maintain bedrest until calculi are
expelled. Withhold thiazide diuretics.
Encourage intake of at least 3 L of fluid each day.
Collect all urine for 24 hr in a collection container.: Encourage intake of at
least 3 L of fluid each day.
The nurse should encourage the client to consume at least 3 L of fluid
each day. Increased fluid intake increases urine production, promotes
eliminiation of calculi, and helps prevent recurrence.
2. A nurse is providing postoperative education for a client following a la-
paroscopic cholecystectomy for cholelithiasis. Which of the following
client statements indicates an understanding of the teaching?
"The adhesive bandages on my incision will fall off as the incision heals."
"I will be able to take a shower in 1 week."
"I will need to follow a liquid diet for the first 3 days after surgery."
"I can begin to resume my normal activity level in 2 weeks.": "The
adhesive bandages on my incision will fall off as the incision heals."
The nurse should instruct the client that the small adhesive bandages
will lose their adhesiveness in 7 to 10 days. The client can then remove
the bandages or allow the bandages to fall off over time as the incision
heals.
3. A nurse is planning care to prevent hospital-acquired methicillin-
resistant Staphylococcus aureus (MRSA) infection for a client who is
immunocom- promised. Which of the following interventions should the
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,nurse include to prevent this antibiotic-resistant infection?
Initiate contact precautions for this client.
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exam
Bathe the client with chlorhexidine wipes.
Administer ceftaroline to the client as a prophylactic measure.
Avoid using alcohol-based hand sanitizers after caring for the client:
Bathe the client with chlorhexidine wipes.
The nurse should bathe a client who is immunocompromised with
chlorhexidine wipes to decrease the risk of contracting hospital-
acquired MRSA.
4. A nurse is assessing a client who has developed type 1 herpes simplex
virus. Which of the following images should the nurse identify as this
type of viral infection?: Picture of lips.
Herpes simplex virus infection is a common viral infection in adults.
The nurse should identify that this image indicates the type 1 herpes
simplex viral infection because the infection causes a recurring cold
sore.
5. A nurse is assessing a client who has Graves' disease. Which of
the following findings should the nurse expect?
Somnolence
Cold intolerance
Exophthalmos
Dry, scaly skin: Exophthalmos
The nurse should expect a client who has Graves' disease, an
autoimmune form of hyperthyroidism, to experience exophthalmos,
which is protrusion of the eyeballs.
6. A nurse is teaching an older adult client who has peripheral
neuropathy about a new prescription for duloxetine. Which of the following
client state- ments indicates an understanding of the teaching?
"It might take several weeks to notice an improvement in my
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symptoms." "I will need to take this medication on an empty stomach."
"I should take a daily ibuprofen for generalized aches."
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