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 ["B","C","D","F"]

Explanation

A. Vomiting is not a common side effect of phenytoin but could occur in some patients. It’s more likely a
reaction to the medication rather than a frequent side effect.
B. Phenytoin can affect blood coagulation. It may interfere with vitamin K metabolism, which can alter coagulation pathways and increase the risk of bleeding or bruising. Monitoring for signs of bleeding or changes in clotting status is important, particularly in patients on long-term therapy.
C. Visual disturbances, including nystagmus (involuntary eye movements), double vision, or blurred vision, can occur with phenytoin use. This side effect is related to the medication’s impact on the nervous system.
D. Drowsiness is a common side effect of many antiepileptic drugs, including phenytoin. It can affect the client’s alertness and overall level of consciousness, making it important for the nurse to monitor and address any related safety concerns.
E. Aphasia, or difficulty with language and speech, is not a typical side effect of phenytoin. While phenytoin affects the central nervous system, aphasia is not commonly reported with its use.
F. Ataxia, or lack of coordination and unsteady movements, is a known side effect of phenytoin. This occurs due to its effects on the nervous system and can impair motor skills and coordination.

A. Encourage active range of motion exercises. B. Assist with ambulation in the hallway. C. Provide a bedside commode for toileting. D. Teach to sleep in a side lying position.

Correct Answer is C

Explanation

A. Range of motion exercises are important for overall mobility and prevention of complications from immobility. However, they can increase cardiac workload, especially if performed actively and without supervision.
B. Ambulation, or walking in the hallway, increases cardiac workload and can exacerbate symptoms in a client with unstable angina. This activity should be minimized or restricted until the client's condition stabilizes. The focus should be on reducing activities that put additional stress on the heart.

C. Using a bedside commode helps reduce the need for the client to walk to the bathroom, which can be physically demanding and increase cardiac workload. By minimizing the effort required for toileting, the client can avoid unnecessary physical strain.
D. Sleeping in a side-lying position is not directly related to reducing cardiac workload. The client's position during sleep generally does not have as significant an impact on cardiac workload as other interventions.

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

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Naxlex Comprehensive Predictor Exams

Exhibits The healthcare provider comes to the bedside following the seizure and prescribes phenytoin. The nurse administers the phenytoin as prescribed. Which possible side effect(s) of phenytoin should the nurse assess for after administration? Select all that apply.

Correct Answer is ["B","C","D","F"]

Explanation

A client with coronary artery disease is hospitalized with unstable angina. To reduce cardiac workload, which intervention should the nurse include in the client's plan of care?

Correct Answer is C

Explanation

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While assessing a client with type 2 diabetes mellitus (DM), the nurse observes an absence of hair growth on the client's lower legs. Which assessment provides further data to support this finding?

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