Which assessment finding is most important to report to the health care provider regarding a patient who has had left-sided extracorporeal shock wave lithotripsy?
a. Blood in urine
b. Left flank bruising
c. Left flank discomfort
d. Decreased urine output
ANS: D
Because lithotripsy breaks the stone into small sand, which could cause obstruction, it is important to report a drop in urine output. Left flank pain, bruising, and hematuria are common after lithotripsy.
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A 17-year-old client whose boyfriend was killed in a car accident says that God punished her by taking her boyfriend because they had been living together and were not married. What kind of response by the nurse would be most helpful?
1. "God does not punish people in that manner." 2. "You're right, you should have gotten married." 3. "What is your religion?" 4. "Tell me about your boyfriend."
The nurse knows that, if left untreated, the patient with bulimia nervosa is at risk for which priority nursing diagnosis?
1. Fatigue 2. Powerlessness 3. Risk for injury 4. Coping, Ineffective
The nurse is conducting discharge teaching for a client going home after a cesarean birth. Which signs and symptoms should the client be taught to report? (Select all that apply.)
a. Mild incisional pain b. Feeling of pelvic fullness c. Lochia changing from red to pink in color d. Frequency, urgency, or burning on urination e. Redness or edema of the abdominal incision
Which task is appropriate for the nurse to delegate to a licensed practical/vocational nurse (LPN/LVN)?
a. Complete the initial admission assessment and plan of care. b. Document teaching completed before a diagnostic procedure. c. Instruct a patient about low-fat, reduced sodium dietary restrictions. d. Obtain bedside blood glucose on a patient before insulin administration.