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A nurse is assessing a client who has right-sided heart failure. Which of the following findings should the nurse expect?
- A. Elevated blood glucose.
- B. Decreased urine output.
- C. Dependent edema.
- D. Jaundice.
Correct Answer: C
Rationale: The correct answer is C: Dependent edema. In right-sided heart failure, the heart is unable to effectively pump blood to the lungs for oxygenation, leading to fluid accumulation in the systemic circulation. This fluid backs up in the venous system, causing increased pressure in the veins of the body, resulting in dependent edema, usually starting in the lower extremities. Elevated blood glucose (choice A) is not directly related to right-sided heart failure. Decreased urine output (choice B) may occur in conditions like acute kidney injury but is not a specific finding of right-sided heart failure. Jaundice (choice D) is more commonly associated with liver dysfunction, not typically seen in right-sided heart failure.
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A nurse is collecting data from a client who has Tourette syndrome. The client reports taking haloperidol 0.5 mL orally three times a day at home. Which of the following components of the prescription should the nurse question?
- A. Frequency
- B. Dosage
- C. Timing of doses
- D. Route
Correct Answer: B
Rationale: The nurse should question the dosage of haloperidol as it is typically administered in milligrams (mg) and not milliliters (mL). The dosage should be expressed in a standardized unit for accuracy and to prevent medication errors. Frequency, timing of doses, and route are also important components of a prescription, but in this case, the nurse should focus on the unusual dosage form.
What is the primary intervention for sepsis?
- A. Administer IV antibiotics
- B. Monitor blood pressure
- C. Administer fluids
- D. All of the above
Correct Answer: D
Rationale: The primary intervention for sepsis involves a multifaceted approach, including administering IV antibiotics to address the underlying infection and administering fluids to stabilize the patient's hemodynamic status. Monitoring blood pressure is important in the management of sepsis, but it is not the sole primary intervention. Therefore, the correct answer is 'All of the above' as it encompasses the comprehensive approach required for effective sepsis management.
A nurse is caring for a client who has a serum sodium level of 125 mEq/L. Which of the following findings should the nurse expect?
- A. Numbness of the extremities.
- B. Abdominal cramping.
- C. Bradycardia.
- D. Positive Chvostek's sign.
Correct Answer: B
Rationale: Abdominal cramping is a common manifestation of hyponatremia, as the sodium imbalance affects muscle function. Numbness of the extremities (Choice A) is more commonly associated with electrolyte imbalances such as hypocalcemia. Bradycardia (Choice C) is not typically a direct manifestation of hyponatremia. Positive Chvostek's sign (Choice D) is related to hypocalcemia, not hyponatremia.
A nurse is caring for a client who has dementia and frequently gets out of bed unsupervised. What is the best intervention to prevent falls?
- A. Place a bed exit alarm
- B. Use restraints to prevent the client from getting out of bed
- C. Ask the client's family to stay at the bedside
- D. Encourage frequent ambulation with assistance
Correct Answer: A
Rationale: The best intervention to prevent falls in a client with dementia who gets out of bed unsupervised is to place a bed exit alarm. This device alerts staff when the client attempts to leave the bed, allowing timely intervention to reduce the risk of falls. Using restraints (choice B) can lead to physical and psychological harm and should be avoided unless absolutely necessary. Asking the client's family to stay at the bedside (choice C) may not be feasible at all times and does not provide a continuous monitoring solution. Encouraging frequent ambulation with assistance (choice D) is beneficial for mobility but may not address the immediate risk of falls associated with unsupervised bed exits.
A client needs a 24-hour urine collection initiated. Which of the following client statements indicates an understanding of the procedure?
- A. I had a bowel movement, but I was able to save the urine.
- B. I have a specimen in the bathroom from about 30 minutes ago.
- C. I flushed what I urinated at 7 am and have saved the rest since.
- D. I drink a lot, so I will fill up the bottle and complete the test quickly.
Correct Answer: C
Rationale: Choice C is correct because it demonstrates the client's understanding of the procedure, which involves discarding the first urine of the day at the specified time and then saving all subsequent urine for the next 24 hours. Choices A, B, and D do not reflect an understanding of the correct procedure. Choice A is incorrect because bowel movements are not part of a 24-hour urine collection. Choice B is incorrect as it does not specify discarding the first urine. Choice D is incorrect as it mentions filling up the bottle quickly, which is not the correct way to collect a 24-hour urine sample.