Nokea
A 15 year-old high school wrestler has been taking diuretics to lose weight to compete in a lower weight class. Which of the following medical tests is most likely to be given?
- A. Lab values of Potassium and Sodium
- B. Lab values of glucose and hemoglobin
- C. ECG
- D. CT scan
Correct Answer: A
Rationale: Diuretics can disturb the sodium and potassium balance, resulting in cardiac complications. Monitoring electrolyte levels is critical.
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Which of the following is least relevant when reviewing the client's risk for elimination impairment?
- A. current medications
- B. ambulation abilities
- C. family history
- D. hydration status
Correct Answer: C
Rationale: The client's family history is least relevant when determining the risk for elimination impairment.
Mrs. Peterson complains of difficulty falling asleep, awakening earlier than desired, and not feeling rested. She attributes these problems to leg pain that is secondary to her arthritis. What is the most appropriate nursing diagnosis for her?
- A. Sleep Pattern Disturbances (related to arthritis)
- B. Fatigue (related to leg pain)
- C. Knowledge Deficit (regarding sleep hygiene measures)
- D. Sleep Pattern Disturbances (related to chronic leg pain)
Correct Answer: D
Rationale: The client's sleep pattern is directly disturbed by the chronic leg pain, which is secondary to the arthritis. This nursing diagnosis is the appropriate one to directly deal with comfort measures and the like.
Pressure ulcers usually occur:
- A. When clients are left in one position in bed for extended periods of time
- B. When clients are underweight
- C. When clients are overweight
- D. Only in underweight and overweight clients
Correct Answer: A
Rationale: Pressure ulcers occur over bony prominences due to decreased circulation from prolonged immobility, not specifically related to body weight.
The client with diarrhea has had four bowel movements in the past eight hours, measuring 150 mL, 100 mL, 100 mL and 150 mL. The client is to receive one-to-one replacement with a bolus of IV 0.9% NaCl to be infused over the next two hours. How many mL of 0.9% NaCl will the nurse infuse each hour?
Correct Answer: 250
Rationale: Total loss is 500 mL (150+100+100+150). One-to-one replacement means 500 mL over 2 hours, so 500/ 2 = 250 mL per hour.
The 24-hour day-night cycle is known as:
- A. circadian rhythm
- B. infradian rhythm
- C. ultradian rhythm
- D. non-REM rhythm
Correct Answer: A
Rationale: The circadian rhythm governs the 24-hour cycle of physiological processes. Infradian rhythms are longer than 24 hours (e.g., menstrual cycle), ultradian rhythms are shorter (e.g., sleep cycles), and non-REM rhythm is not a recognized term.