Nokea
Postoperative client with fluid volume deficit. Which change indicates successful treatment?
- A. Decrease in heart rate
- B. Increase in blood pressure
- C. Decrease in respiratory rate
- D. Increase in urine output
Correct Answer: A
Rationale: A decrease in heart rate can indicate improved fluid balance and successful treatment of fluid volume deficit. When a client is experiencing fluid volume deficit, the heart rate typically increases as a compensatory mechanism to maintain cardiac output. As fluid volume is restored and the deficit is corrected, the heart rate should decrease back towards a normal range. Choices B, C, and D are less likely to be directly related to the successful treatment of fluid volume deficit. An increase in blood pressure may occur as a compensatory response to fluid volume deficit; a decrease in respiratory rate is not a typical indicator of fluid volume deficit correction; and an increase in urine output can be a sign of improved kidney function but may not directly reflect fluid volume status.
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While auscultating a client's abdomen, a nurse hears a blowing sound over the aorta. The nurse should identify this sound as which of the following?
- A. Gallop
- B. Bruit
- C. Thrill
- D. Murmur
Correct Answer: B
Rationale: The correct answer is B: Bruit. A bruit is a blowing sound indicating turbulent blood flow, often heard over the aorta. Choices A, C, and D are incorrect. A gallop is a cardiac sound resembling the sound of a galloping horse. A thrill is a vibration felt on palpation, and a murmur is a swooshing or whooshing sound heard during auscultation of the heart or blood vessels. In this scenario, the blowing sound over the aorta specifically indicates a bruit, which signifies turbulent blood flow and should be further assessed by the healthcare provider.
How should the nurse transcribe the dosage of this medication on the client's medical record?
- A. 0.3 mg
- B. 0.3 mg
- C. 0.30 mg
- D. 3/10 mg
Correct Answer: B
Rationale: The correct way to transcribe the dosage of three tenths of a milligram of levothyroxine IV STAT is 0.3 mg. When expressing decimals less than 1, there should be a leading zero before the decimal point. Choice A is incorrect (.3 mg) because it lacks the leading zero. Choice C (0.30 mg) is incorrect as it includes a trailing zero after the decimal point, which is unnecessary. Choice D (3/10 mg) is incorrect as it presents the dosage as a fraction, which is not the standard format for transcribing medication dosages. Therefore, B (0.3 mg) is the most appropriate and accurate way to document this prescription on the client's medical record.
A client is being treated for paranoid schizophrenia. When the client became loud and boisterous, the nurse immediately placed him in seclusion as a precautionary measure. The client willingly complied. The nurse's action:
- A. May result in charges of unlawful seclusion and restraint
- B. Leaves the nurse vulnerable to charges of assault and battery
- C. Was appropriate given the client's history of violence
- D. Was necessary to maintain the therapeutic milieu of the unit
Correct Answer: A
Rationale: Placing a client in seclusion without proper justification and documentation can lead to charges of unlawful seclusion and restraint, regardless of the client's compliance. This legal issue arises from the potential violation of the client's rights and must be avoided. Choice B is incorrect as the situation does not involve assault and battery. Choice C is incorrect as past violence alone does not justify seclusion without immediate risk. Choice D is incorrect as seclusion should be used based on individual risk and necessity, not solely for maintaining the therapeutic milieu.
The nurse is evaluating client learning about a low-sodium diet. Selection of which meal would indicate to the LPN that this client understands the dietary restrictions?
- A. Tossed salad with low-sodium dressing, bacon, and tomato sandwich.
- B. New England clam chowder, unsalted crackers, fresh fruit salad.
- C. Skim milk, turkey salad, roll, and vanilla ice cream.
- D. Macaroni and cheese, diet Coke, and a slice of cherry pie.
Correct Answer: C
Rationale: The correct answer is C: Skim milk, turkey salad, roll, and vanilla ice cream. These items are low in sodium, making it a suitable meal for someone on a low-sodium diet. Skim milk, turkey salad, and vanilla ice cream are naturally low in sodium, while the roll can be selected as a low-sodium option. Choices A, B, and D contain items that are typically high in sodium, such as bacon, clam chowder, crackers, and cheese, making them unsuitable for a low-sodium diet.
A nurse is caring for a client who has herpes zoster. The client asks about complementary and alternative therapies for pain control. The nurse should inform the client that this condition is a contraindication for which of the following therapies?
- A. Acupuncture
- B. Massage therapy
- C. Aromatherapy
- D. Herbal supplements
Correct Answer: A
Rationale: The correct answer is A, Acupuncture. Acupuncture is contraindicated for clients with herpes zoster due to the risk of infection at the needle sites. In individuals with herpes zoster, the skin's integrity is compromised, increasing susceptibility to infections. Therefore, acupuncture, which involves inserting needles into the skin, can introduce pathogens and lead to local infections. Massage therapy (B), aromatherapy (C), and herbal supplements (D) do not involve skin penetration like acupuncture and are generally considered safe complementary therapies for pain control in clients with herpes zoster.