Question

A client has been admitted through the Emergency Department with a diagnosis of renal calculi. While waiting for test results, the client cries out "can I please have something for pain?" Which nursing action is most appropriate?

Answer 1

Correct Answers:

Administer opioid analgesics as ordered.

Rationale :

💊The most appropriate intervention for a client with renal calculi is administration of opioid analgesics because the pain is severe and colicky in nature.

🔥The pain associated with renal calculi often results from obstruction and stretching of the urinary tract, making non-pharmacologic measures insufficient in acute cases.

👩‍⚕️Administering opioids as prescribed ensures prompt relief, allows for diagnostic testing, and prevents further physiological stress from uncontrolled pain.

📋Other options like deep breathing, ambulation, or fluid intake are supportive but do not address the immediate acute pain, making opioids the correct priority intervention.

📌Core Message

The priority nursing intervention for severe renal calculi pain is to administer opioid analgesics as ordered because non-pharmacologic measures are not sufficient in acute pain management.

Answer 2

Correct Answers

"I will assess on a daily basis whether the indwelling urinary catheter remains necessary." [ Safe ]
"I will check all medication labels at least two times before administering them to patients." [ Safe ]
"I will wear a N95 mask (that I will be properly fitted for) when entering an Airborne Transmission-based Precaution room." [ Safe ]
"I will identify the patients using their birth dates and room numbers." [ Unsafe ]
"I will wear sterile gloves when changing a central line dressing." [ Safe ]

Rationale :

🧴Sterile gloves must be worn for central line dressing changes to prevent central line-associated bloodstream infections (CLABSI).

😷N95 mask use is required for airborne precautions, such as tuberculosis, ensuring infection prevention.

💊Checking medication labels twice is a key medication safety standard to prevent errors.

🩺Assessing the need for a catheter daily prevents catheter-associated urinary tract infections (CAUTI).

🚫Using birth date and room number is unsafe because room numbers change and birth dates are not unique identifiers; correct practice is using two unique identifiers like name and date of birth.

📌Core Message

Safe practices include sterile technique, proper PPE, double-checking medications, and reassessing catheter need, while unsafe practice is using unreliable identifiers like room numbers.

Answer 3

Correct Answers:

Elevated uric acid levels
Diet high in animal protein
Frequent urinary tract infections (UTIs)
Excessive intake of calcium based antacids
Inadequate fluid intake

Rationale :

🧪Elevated uric acid levels increase risk by promoting uric acid stone formation, which is a modifiable metabolic factor.

🥩A diet high in animal protein contributes to acidic urine, enhancing the risk of stone formation.

🦠Frequent UTIs predispose to struvite stone formation, making it a modifiable factor with treatment.

💊Excessive use of calcium-based antacids can elevate urinary calcium, increasing calcium stone risk.

🚰Inadequate fluid intake leads to concentrated urine, which is the most significant modifiable risk factor for renal calculi.

👨‍👩‍👦Family history is non-modifiable, hence excluded.

📌Core Message

Modifiable risk factors for renal calculi include elevated uric acid, high protein diet, recurrent UTIs, calcium antacid overuse, and inadequate fluid intake, while family history is non-modifiable.

Answer 4

Correct Answers

Abdominal engorgement (ascites) [ right-sided HF ]
Jugular vein distention [ right-sided HF ]
Decreasing BP readings [ left-sided HF ]
Dependent edema [ right-sided HF ]
Decreased urinary output [ left-sided HF ]
Crackles, wheezes, dyspnea, and cough [ left-sided HF ]

Rationale :

📉Left-sided HF leads to pulmonary congestion because of fluid backing up into the lungs, causing crackles, dyspnea, and cough.

💦Decreased cardiac output in left-sided HF results in low BP and reduced urine output.

🌊Right-sided HF causes systemic venous congestion leading to JVD, ascites, and dependent edema.

🔄Right-sided HF often results from prolonged left-sided HF, showing interdependence of both conditions.

📌Core Message

Left-sided HF causes pulmonary congestion and low perfusion, while right-sided HF leads to systemic venous congestion signs such as edema, ascites, and JVD.

Answer 5

Correct Answers:

The nurse calls the respiratory therapist to meet and educate the patient how to administer breathing treatments at home.

Rationale :

🤝Collaboration involves working with other healthcare professionals to optimize patient care.

💁‍♂️Calling a respiratory therapist ensures specialized teaching in breathing treatment techniques.

👩‍⚕️The nurse’s role is to coordinate care and ensure the patient receives the right expertise from the right professional.

📚This improves patient outcomes by reinforcing knowledge from both nurse and therapist.

📌Core Message

Collaboration in COPD care involves including the respiratory therapist for patient education on breathing treatments, ensuring multidisciplinary care.

Answer 6

Correct Answers:

Constipation or altered bowel habits
Abdominal distention and tenderness
Elevated white blood cell count
Elevated temperature

Rationale :

💩Constipation or altered bowel habits are common due to inflammation and obstruction in diverticulitis.

🩺Abdominal distention and tenderness occur from inflamed diverticula causing localized discomfort.

🧪An elevated WBC count reflects the inflammatory process associated with infection.

🌡️Fever (elevated temperature) is another hallmark of the acute inflammatory response.

❌Pain localized in the right lower quadrant is more typical of appendicitis, not diverticulitis (usually left lower quadrant).

📌Core Message

Diverticulitis presents with bowel habit changes, abdominal tenderness, fever, and elevated WBCs, but not right-sided abdominal pain.

Answer 7

Correct Answers

"The patient should splint their abdominal incision with pillow or folded blanket." [ Correct ]
"We should encourage patient to sit in the chair all day." [ Incorrect ]
"The patient needs to wear ordered sequential compression devices (SCDs) to prevent deep vein thrombosis (DVT)." [ Correct ]
"Hematuria is expected following surgery." [ Incorrect ]
"The patient needs to blow into the incentive spirometer 8-10 breaths per hour while awake." [ Correct ]

Rationale :

🛏️Splinting the incision helps reduce pain and strain during movement or coughing.

🧦Using SCDs reduces risk of DVT, a serious post-op complication.

💨Incentive spirometry prevents pulmonary complications by promoting lung expansion.

💁‍♂️Prolonged sitting without rest causes fatigue and circulatory issues, not best practice.

🚫Hematuria is not expected post-hysterectomy and may signal complications like injury or infection.

📌Core Message

Correct hysterectomy post-op care includes splinting, SCDs, and incentive spirometry, while prolonged sitting and expecting hematuria indicate misunderstanding.

Answer 8

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

Answer 9

Correct Answers:

100

Rationale :

⚖️Conversion: 22 lb ÷ 2.2 = 10 kg.

💊Daily dose: 20 mg × 10 kg = 200 mg/day.

📆BID dosing: 200 ÷ 2 = 100 mg/dose.

🛡️This ensures the child receives the correct therapeutic dose without risk of under- or over-dosing.

📌Core Message

The safe amoxicillin dose for a 22 lb child is 100 mg per dose when ordered 20 mg/kg/day BID.

Answer 10

Correct Answers:

It is a severe vesicant and can cause tissue necrosis and even loss of limb.

Rationale :

💉Promethazine is a potent vesicant that can cause severe tissue injury if extravasation occurs.

🩺Complications include necrosis, gangrene, and possible limb amputation if administered IV improperly.

🚫Because of this high risk, alternative routes such as oral or intramuscular are preferred.

📋Nurses must be aware of medication administration risks and prioritize patient safety by avoiding high-risk routes when safer alternatives exist.

📌Core Message

IV promethazine is avoided because it is a severe vesicant that may cause tissue necrosis and limb loss, making safer routes preferable.

Statement	Safe	Unsafe
"I will assess on a daily basis whether the indwelling urinary catheter remains necessary."
"I will check all medication labels at least two times before administering them to patients."
"I will wear a N95 mask (that I will be properly fitted for) when entering an Airborne Transmission-based Precaution room."
"I will identify the patients using their birth dates and room numbers."
"I will wear sterile gloves when changing a central line dressing."

Symptom	right-sided HF	left-sided HF
Abdominal engorgement (ascites)
Jugular vein distention
Decreasing BP readings
Dependent edema
Decreased urinary output
Crackles, wheezes, dyspnea, and cough

Statement	Correct	Incorrect
"The patient should splint their abdominal incision with pillow or folded blanket."
"We should encourage patient to sit in the chair all day."
"The patient needs to wear ordered sequential compression devices (SCDs) to prevent deep vein thrombosis (DVT)."
"Hematuria is expected following surgery."
"The patient needs to blow into the incentive spirometer 8-10 breaths per hour while awake."

NUR 195 EXAM 2 Summer 25 Detroit

No.

1 :
A client has been admitted through the Emergency Department with a diagnosis of renal calculi. While waiting for test results, the client cries out "can I please have something for pain?" Which nursing action is most appropriate?

2 :
The experienced LPN is instructing a newly hired LPN about the importance of providing safe care in alignment with the National Patient Safety Goals (NPSG).

Correct Answers

3 :
A nurse is educating a client on risk factors for renal calculi (kidney stones). Which of the following modifiable factors increase the client's risk of developing renal calculi? (Select all that apply.)

4 :
For the following symptoms of heart failure (HF), indicate whether they are associated with right-sided, or left-sided HF.

Correct Answers

5 :
Nurses are caring for a patient experiencing an acute exacerbation of COPD. Which action relates to the concept of Collaboration?

6 :
A client is admitted with a suspected diagnosis of diverticulitis. Which of the following clinical manifestations should the nurse expect to assess in this client? (Select all that apply.)

7 :
During a staff meeting, a nurse presented an in-service about post-op Hysterectomy care.

Correct Answers

8 :
A patient is prescribed morphine 4 mg IV q4h PRN pain. The safe dose range is 0.05-0.2 mg/kg/dose. The patient weighs 70 kg. Is the ordered dose safe? Show the safe range in mg.

9 :
A child weighs 22 lb and is ordered amoxicillin 20 mg/kg/day. The medication is ordered BID. How many mg should the nurse administer per dose?

10 :
Why is promethazine (phenergan) intravenous route often avoided?

NUR 195 EXAM 2 Summer 25 Detroit

No.

1 : A client has been admitted through the Emergency Department with a diagnosis of renal calculi. While waiting for test results, the client cries out "can I please have something for pain?" Which nursing action is most appropriate?

2 : The experienced LPN is instructing a newly hired LPN about the importance of providing safe care in alignment with the National Patient Safety Goals (NPSG).

Correct Answers

3 : A nurse is educating a client on risk factors for renal calculi (kidney stones). Which of the following modifiable factors increase the client's risk of developing renal calculi? (Select all that apply.)

4 : For the following symptoms of heart failure (HF), indicate whether they are associated with right-sided, or left-sided HF.

Correct Answers

5 : Nurses are caring for a patient experiencing an acute exacerbation of COPD. Which action relates to the concept of Collaboration?

6 : A client is admitted with a suspected diagnosis of diverticulitis. Which of the following clinical manifestations should the nurse expect to assess in this client? (Select all that apply.)

7 : During a staff meeting, a nurse presented an in-service about post-op Hysterectomy care.

Correct Answers

8 : A patient is prescribed morphine 4 mg IV q4h PRN pain. The safe dose range is 0.05-0.2 mg/kg/dose. The patient weighs 70 kg. Is the ordered dose safe? Show the safe range in mg.

9 : A child weighs 22 lb and is ordered amoxicillin 20 mg/kg/day. The medication is ordered BID. How many mg should the nurse administer per dose?

10 : Why is promethazine (phenergan) intravenous route often avoided?

1 :
A client has been admitted through the Emergency Department with a diagnosis of renal calculi. While waiting for test results, the client cries out "can I please have something for pain?" Which nursing action is most appropriate?

2 :
The experienced LPN is instructing a newly hired LPN about the importance of providing safe care in alignment with the National Patient Safety Goals (NPSG).

3 :
A nurse is educating a client on risk factors for renal calculi (kidney stones). Which of the following modifiable factors increase the client's risk of developing renal calculi? (Select all that apply.)

4 :
For the following symptoms of heart failure (HF), indicate whether they are associated with right-sided, or left-sided HF.

5 :
Nurses are caring for a patient experiencing an acute exacerbation of COPD. Which action relates to the concept of Collaboration?

6 :
A client is admitted with a suspected diagnosis of diverticulitis. Which of the following clinical manifestations should the nurse expect to assess in this client? (Select all that apply.)

7 :
During a staff meeting, a nurse presented an in-service about post-op Hysterectomy care.

8 :
A patient is prescribed morphine 4 mg IV q4h PRN pain. The safe dose range is 0.05-0.2 mg/kg/dose. The patient weighs 70 kg. Is the ordered dose safe? Show the safe range in mg.

9 :
A child weighs 22 lb and is ordered amoxicillin 20 mg/kg/day. The medication is ordered BID. How many mg should the nurse administer per dose?

10 :
Why is promethazine (phenergan) intravenous route often avoided?