1. a nurse is assessing a client who had extracorporeal shock wake lithotripsy (ESWL) 6 hr ago. which of the following findings should the nurse expect?

ANS: stone fragments in the urine

RATIONALE: ESWL is an effort to break the calculi so that the fragments pass down the ureter, into the bladder, and through the urethra during voiding. Following the procedure, the nurse should strain the client's urine to confirm the passage of stones.

2. a nurse is assessing a group of clients for indications of role changes. the nurse should identify that which of the following clients is at risk for experiencing a role change?

ANS: a client who has multiple sclerosis and is experiencing progressive difficulty ambulating.

RATIONALE: The nurse should identify that progression of a neurologic disease such as multiple sclerosis can lead to a role change as the client becomes less independent.

3. a nurse is caring for a client who has a new diagnosis of hyperthyroidism. which of the following is the priority assessment finding that the nurse should report to the provider?

ANS: blood pressure 170/80 mm Hg

RATIONALE: Using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is a systolic blood pressure of 170 mm Hg, which indicates that the client is at risk for thyroid storm.

4. a nurse is providing discharge instructions to a client who has a partial-thickness burn on the hand. which of the following instructions should the nurse include?

ANS: wrap fingers with individual dressings.

RATIONALE: The nurse should instruct the client to wrap the fingers individually to allow for functional use of the hand while healing occurs. The nurse should also instruct the client to perform range-of-motion exercises to each finger every hour while awake to promote function of the injured hand.

5. a nurse is providing teaching to a client who is receiving chemotherapy and has a new prescription for epoetin alfa. which of the following client statements indicates an understanding of the teaching?

ANS: I will monitor my blood pressure while taking this medication