While assessing a client following lithotripsy with stent insertion, which data indicates to the nurse that the procedure was successful?

Stone fragments are collected when straining the client's urine.

Client denies urinary frequency, urgency, or dysuria.

Urine is pale pink with no observable blood clots.

Serum creatinine and blood urea nitrogen (BUN) levels are within normal limits.

Answer and Explanation

The Correct Answer is A

A.   This directly indicates that the lithotripsy procedure was successful in breaking down the stone into smaller fragments that can be passed through the urinary tract.
B.   While the absence of these symptoms is a positive sign, it does not directly confirm the success of the lithotripsy procedure. These symptoms can be present even if the stone has been broken down.
C.   Pale pink urine is expected after lithotripsy due to minor bleeding. The absence of blood clots is also a good sign, but it doesn't definitively confirm the procedure's success.
D.   Serum creatinine and blood urea nitrogen (BUN) levels are within normal limits. These lab values are important indicators of kidney function but do not directly relate to the success of the lithotripsy procedure itself.

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Correct Answer is A

Explanation

A. Clear breath sounds indicate effective ventilation and oxygenation, which are the desired outcomes of incentive spirometry. This outcome directly reflects the effectiveness of the incentive spirometer in preventing atelectasis and improving lung expansion.
B. A productive cough suggests mobilization of secretions. While this is important for airway clearance, it is not a direct measure of the effectiveness of the incentive spirometer. This outcome is related to airway clearance, but not specifically to the incentive spirometer's role in lung expansion.
C. This outcome measures the client's ability to use the device correctly but does not assess the effectiveness of the device in improving lung function. This outcome is important but does not directly address the goal of the incentive spirometer.
D. This outcome measures compliance with the therapy but does not assess its effectiveness in improving lung function. This outcome is important for adherence but does not directly address the goal of the incentive spirometer.

A. Plan to assess the client's cognition after returning to his room. B. Confirm that this is an effective technique to help with ambulation. C. Reorient the client to his present location and circumstances. D. Assist the client to a carpeted area where he can walk more easily.

Correct Answer is B

Explanation

A. While assessing cognition is important for understanding the client’s overall functioning, the immediate issue of "freezing" during ambulation is more related to motor symptoms rather than cognitive impairment. "Freezing" in Parkinson's disease is a common motor symptom where the client feels as if their feet are glued to the floor.
B. The technique of pretending to step over an imaginary object (like a crack) is known to be a helpful strategy for managing "freezing" in Parkinson's disease. This technique provides a cognitive cue that can help the client initiate movement and overcome the freezing episodes. Confirming that this is an effective technique acknowledges the client's strategy and supports their efforts to improve mobility.

C. Reorienting the client to their location and circumstances can be helpful in situations where confusion or disorientation is an issue. However, in the case of "freezing" during ambulation, this response does not directly address the motor symptoms associated with Parkinson's disease. The problem here is more about movement initiation rather than orientation.
D. Moving to a carpeted area might help with traction and reduce the risk of slipping, but it does not directly address the issue of "freezing" episodes. The freezing phenomenon in Parkinson's disease is related to motor control rather than the type of flooring. While providing a safer walking environment is beneficial, it doesn’t target the underlying motor symptoms as directly as addressing the client’s technique.

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While assessing a client following lithotripsy with stent insertion, which data indicates to the nurse that the procedure was successful?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is evaluating the effectiveness of the incentive spirometer implemented in the client's plan of care. Which outcome statement best describes the effectiveness of the incentive spirometer?

Correct Answer is A

Explanation

The nurse assists a client with Parkinson's disease (PD) to ambulate in the hallway. The client appears to "freeze" and then carefully lifts one leg and steps forward. The client tells the nurse of pretending to step over a crack on the floor. How should the nurse respond?

Correct Answer is B

Explanation

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