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A nurse in an emergency department is assessing a client who is overusing prescribed diuretics and has a sodium level of 127 mEq/L. Which of the following laboratory findings should the nurse expect?
- A. Low urine specific gravity
- B. High urine specific gravity
- C. Elevated potassium levels
- D. Decreased potassium levels
Correct Answer: A
Rationale: The correct answer is A: Low urine specific gravity. Excessive diuretic use can lead to volume depletion and low sodium levels. Low sodium levels cause the kidneys to excrete more water, resulting in dilute urine with low specific gravity. High urine specific gravity would indicate concentrated urine, which is not expected in this situation. Elevated potassium levels (choice C) are not typically associated with overuse of diuretics, as diuretics can actually lead to potassium loss. Similarly, decreased potassium levels (choice D) are commonly seen with diuretic use due to increased excretion of potassium by the kidneys.
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A nurse is providing preoperative teaching to an older adult client who is scheduled for surgery. Which of the following actions should the nurse take to promote learning?
- A. Speak loudly when addressing the client.
- B. Connect new information with the clients past experiences.
- C. Present the information to the client using abstract concepts.
- D. Use a 12-point font when printing written materials for the client.
Correct Answer: B
Rationale: The correct answer is B: Connect new information with the client's past experiences. This is effective because it helps the client relate the new information to what they already know, making it easier to understand and remember. By linking the new information to familiar experiences, the client is more likely to retain the information. Speaking loudly (A) may be unnecessary and could be perceived as patronizing. Presenting information using abstract concepts (C) can confuse the client, especially an older adult. Using a 12-point font (D) may aid readability but does not directly promote learning.
A nurse is planning care for a client who had a lumbar laminectomy. Which of the following interventions should the nurse include in the plan of care?
- A. Encourage the client to ambulate independently.
- B. Turn the client by log rolling with a turning sheet.
- C. Position the client in a high Fowlers position.
- D. Apply a heating pad to the lower back.
Correct Answer: B
Rationale: The correct answer is B: Turn the client by log rolling with a turning sheet. This is the correct intervention because after a lumbar laminectomy, it is crucial to protect the surgical site and avoid bending or twisting the spine. Log rolling with a turning sheet helps maintain proper alignment and prevent injury to the surgical area.
Choice A is incorrect because encouraging the client to ambulate independently may put stress on the surgical area. Choice C is incorrect as positioning the client in a high Fowler's position may also strain the spine. Choice D is incorrect because applying a heating pad to the lower back can increase the risk of burns and should be avoided near a surgical site.
A nurse is planning preventative strategies for a client who is at risk for pressure injuries. Which of the following actions should the nurse include in the plan?
- A. Apply moisturizer to damp skin after bathing.
- B. Massage bony prominences to improve circulation.
- C. Use cornstarch powder to keep skin dry.
- D. Position the client at a 90-degree angle in bed.
Correct Answer: A
Rationale: The correct answer is A: Apply moisturizer to damp skin after bathing. Moisturizing helps maintain skin integrity and hydration, reducing the risk of pressure injuries. When skin is damp, it is more receptive to hydration, which can prevent dryness and breakdown. Applying moisturizer also helps to maintain the skin's natural barrier function. Massaging bony prominences (choice B) can actually increase the risk of pressure injuries by causing friction and shearing forces. Using cornstarch powder (choice C) can lead to moisture buildup and increase the risk of skin breakdown. Positioning the client at a 90-degree angle in bed (choice D) is not a recommended preventive strategy for pressure injuries.
A nurse is caring for a 75-year-old client who is admitted to the medical-surgical unit. Which of the following findings indicate the client is most likely experiencing deep vein thrombosis (DVT)?
- A. Unilateral right lower extremity swelling and warmth below the knee
- B. Pain level as 2 on a scale of 0 to 10
- C. Ambulating in hallway with assistance
- D. Not wearing sequential compression devices
Correct Answer: A
Rationale: The correct answer is A. Unilateral right lower extremity swelling and warmth below the knee are classic signs of deep vein thrombosis (DVT). The swelling occurs due to blood clot formation, leading to impaired venous return and warmth due to inflammation. Choice B is incorrect because pain level alone is not a specific indicator of DVT. Choice C is incorrect as ambulating with assistance does not directly relate to DVT. Choice D is incorrect as not wearing sequential compression devices does not definitively indicate DVT.
A nurse is caring for a client who has developed acute respiratory distress syndrome (ARDS). Which of the following findings should the nurse identify as a manifestation of this syndrome?
- A. Bronchoconstriction
- B. Refractory hypoxemia
- C. Pulmonary hypertension
- D. Pleural effusion
Correct Answer: B
Rationale: Correct Answer: B - Refractory hypoxemia.
Rationale: ARDS is characterized by severe hypoxemia that persists despite high levels of oxygen therapy, known as refractory hypoxemia. This occurs due to ventilation-perfusion mismatch and impaired gas exchange in the alveoli. The other choices are not typical manifestations of ARDS:
A: Bronchoconstriction is more commonly seen in asthma or COPD.
C: Pulmonary hypertension may develop as a complication of ARDS but is not a direct manifestation.
D: Pleural effusion may occur in ARDS but is not a defining characteristic.