A nurse is reinforcing teaching with a client who is scheduled for lithotripsy about conditions that can contribute to the formation of renal calculi. Which of the following conditions should the nurse include?
Obesity.
Dehydration.
Iron deficiency.
Protein in the urine.
The Correct Answer is B
Choice A rationale
Obesity is not a direct cause of renal calculi. However, it can be a risk factor due to associated conditions such as metabolic syndrome, diabetes, and hypertension, which can contribute to stone formation. Weight management and a healthy lifestyle can help reduce the risk of kidney stones.
Choice B rationale
Dehydration is a significant risk factor for the formation of renal calculi. When the body is dehydrated, the urine becomes concentrated, leading to the crystallization of minerals and the formation of stones. Adequate hydration is essential in preventing kidney stones by diluting the urine and reducing the concentration of stone-forming substances.
Choice C rationale
Iron deficiency is not associated with the formation of renal calculi. Iron deficiency primarily affects red blood cell production and can lead to anemia. It does not contribute to the crystallization of minerals in the urine or the formation of kidney stones.
Choice D rationale
Protein in the urine, or proteinuria, is not a direct cause of renal calculi. Proteinuria is often a sign of kidney damage or disease but does not lead to stone formation. The presence of protein in the urine should be evaluated to determine the underlying cause and appropriate treatment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Respiratory alkalosis is incorrect. Respiratory alkalosis is characterized by a high pH and low PaCO₂, which is not consistent with the given ABG values. The client’s pH is low (7.22), indicating acidosis, and the PaCO₂ is high (68 mm Hg), indicating a respiratory cause.
Choice B rationale
Respiratory acidosis is correct. Respiratory acidosis occurs when there is an accumulation of carbon dioxide (CO₂) in the blood, leading to a decrease in pH. The given ABG values show a low pH (7.22) and a high PaCO₂ (68 mm Hg), which are indicative of respiratory acidosis. The elevated bicarbonate (28 mEq/L) suggests partial compensation by the kidneys.
Choice C rationale
Metabolic acidosis is incorrect. Metabolic acidosis is characterized by a low pH and low bicarbonate (HCO₃⁻) levels. In this case, the bicarbonate level is elevated (28 mEq/L), which is not consistent with metabolic acidosis. The primary issue is respiratory, as indicated by the high PaCO₂.
Choice D rationale
Metabolic alkalosis is incorrect. Metabolic alkalosis is characterized by a high pH and high bicarbonate levels. The given ABG values show a low pH (7.22), which indicates acidosis, not alkalosis. Additionally, the primary issue is respiratory, as indicated by the high PaCO₂.
Correct Answer is ["A","D"]
Explanation
Choice A rationale
Monitoring the puncture site for hematoma is crucial because a hematoma can indicate bleeding at the puncture site, which can lead to complications such as infection or nerve damage. Hematomas can also cause increased intracranial pressure, which can be dangerous for the patient. Therefore, it is essential to monitor the site closely to ensure that any signs of bleeding are detected early and managed appropriately.
Choice B rationale
Elevating the client’s head of bed is incorrect because it can increase the risk of cerebrospinal fluid (CSF) leakage from the puncture site. After a lumbar puncture, it is recommended to keep the patient in a flat position for several hours to reduce the risk of post-lumbar puncture headache and to allow the puncture site to heal properly. Elevating the head of the bed too soon can disrupt this process and lead to complications.
Choice C rationale
Inserting a urinary catheter is incorrect because it is not a standard procedure following a lumbar puncture. The primary focus after a lumbar puncture is to monitor for complications related to the procedure itself, such as bleeding, infection, or CSF leakage. Inserting a urinary catheter is not necessary unless there is a specific indication for it, such as urinary retention or other urological issues.
Choice D rationale
Encouraging fluid intake is correct because it helps to replenish the CSF that was removed during the lumbar puncture. Increased fluid intake can also help to reduce the risk of post- lumbar puncture headache, which is a common complication. Hydration is important for overall recovery and helps to maintain normal bodily functions.
Choice E rationale
Applying a cervical collar to the client is incorrect because it is not related to the care of a lumbar puncture site. A cervical collar is typically used for patients with neck injuries or conditions affecting the cervical spine. It has no role in the management of a lumbar puncture site and would not provide any benefit in this context.
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