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A 30-year-old male client reports difficulty sleeping due to anxiety about his upcoming surgery. What intervention would be most appropriate for the nurse to suggest?
- A. Suggest taking a mild sedative before bed.
- B. Encourage physical activity before bedtime.
- C. Advise listening to calming music before bed.
- D. Recommend reading a book before bed.
Correct Answer: A
Rationale: The most appropriate intervention for the nurse to suggest to a 30-year-old male client experiencing difficulty sleeping due to anxiety about his upcoming surgery is to recommend taking a mild sedative before bed. A mild sedative can help manage anxiety and improve sleep in such situations. Encouraging physical activity before bedtime, advising to listen to calming music, or recommending reading a book may not directly address the client's anxiety and may not be as effective in promoting sleep in this scenario.
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A client with a ruptured spleen underwent an emergency splenectomy. Twelve hours later, the client's urine output is 25 ml/hour. What is the most likely cause?
- A. This is a normal finding after surgery.
- B. Oliguria signals tubular necrosis related to hypoperfusion.
- C. Oliguria signals dehydration and fluid loss.
- D. Urine output of 25 ml/hour is an expected finding after splenectomy.
Correct Answer: B
Rationale: Oliguria, or decreased urine output, after surgery can indicate tubular necrosis due to hypoperfusion, which may require intervention to restore renal function. Choice A is incorrect as oliguria is not a normal finding after surgery. Choice C is incorrect because dehydration is less likely in this context compared to tubular necrosis. Choice D is incorrect as a urine output of 25 ml/hour is not expected after splenectomy and should raise concern for renal impairment.
The nurse is taking the blood pressure measurement of a client with Parkinson's disease. Which information in the client's admission assessment is relevant to the nurse's plan for taking the blood pressure reading?
- A. Frequent syncope
- B. Muscle rigidity
- C. Gait instability
- D. Fine motor tremors
Correct Answer: A
Rationale: The correct answer is A: 'Frequent syncope.' Orthostatic hypotension, common in Parkinson's disease, often causes syncope (fainting) when blood pressure drops upon standing. This information is critical for planning safe blood pressure measurements, ensuring readings are taken in both lying and standing positions to assess for sudden drops in pressure. Muscle rigidity, tremors, or gait instability are important symptoms in Parkinson's disease but are not directly related to blood pressure assessment.
The nurse is planning to administer two medications at 0900. Which property of the drugs indicates a need to monitor the client for toxicity?
- A. Short half-life
- B. High therapeutic index
- C. Highly protein-bound
- D. Low bioavailability
Correct Answer: C
Rationale: The correct answer is C, 'Highly protein-bound.' Drugs that are highly protein-bound can displace from protein-binding sites, leading to increased free drug levels in the blood, which can result in toxicity. Monitoring the client for toxicity is crucial when administering highly protein-bound drugs. Choices A, B, and D are incorrect. A short half-life does not necessarily indicate a need for monitoring toxicity; a high therapeutic index indicates a wide safety margin between the effective dose and the toxic dose, reducing the risk of toxicity; low bioavailability refers to the fraction of the drug that reaches the systemic circulation unchanged and does not directly relate to the risk of toxicity.
A client is admitted to isolation with active tuberculosis. What infection control measures should the nurse implement?
- A. Initiate protective environment precautions.
- B. Use droplet precautions only.
- C. Ensure a positive pressure environment in the room.
- D. Implement negative pressure and contact precautions.
Correct Answer: D
Rationale: When caring for a client with active tuberculosis, it is crucial to implement negative pressure rooms and contact precautions to prevent the spread of infection. Choice A, initiating protective environment precautions, is incorrect as this is not the recommended approach for tuberculosis. Choice B, using droplet precautions only, is insufficient as tuberculosis requires additional precautions. Choice C, ensuring a positive pressure environment in the room, is incorrect because negative pressure rooms are necessary to contain airborne pathogens like tuberculosis. Therefore, the most appropriate measures include implementing negative pressure rooms and contact precautions.
A client is receiving IV antibiotic therapy for sepsis. Which assessment finding indicates that the client's condition is improving?
- A. Urine output increases to 25 mL/hour
- B. Client reports feeling less fatigued
- C. Heart rate decreases from 120 to 110 beats per minute
- D. White blood cell count decreases from 15,000 to 9,000/mm3
Correct Answer: D
Rationale: The correct answer is D. A decrease in white blood cell count indicates that the infection is responding to treatment, making this the most objective indicator of improvement in a client with sepsis. Choices A, B, and C are subjective indicators and may not always directly correlate with the resolution of the underlying infection. While an increase in urine output, a client reporting feeling less fatigued, and a decrease in heart rate are positive signs, they are not as specific or directly related to the resolution of the infection as a decrease in white blood cell count.