Nokea
A 68-year-old client has an order for hydrochlorothiazide (Hydrodiuril) 50 mg qd. The nurse knows that teaching has been successful if the client makes which of the following statements?
- A. I should not operate heavy machinery.
- B. I should drink only five glasses of liquid per day.
- C. This medication will cause my urine to turn orange.
- D. I should eat dried apricots each day.
Correct Answer: D
Rationale: Hydrochlorothiazide causes potassium loss; eating potassium-rich apricots indicates understanding. Options A, B, and C are incorrect.
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The nurse is caring for a client who is receiving IV fluids at 125 mL/hour. Which of the following findings would be of GREATest concern to the nurse?
- A. Blood pressure of 130/80 mmHg.
- B. Heart rate of 88 bpm.
- C. Respiratory rate of 24 breaths/min.
- D. Urine output of 100 mL/hour.
Correct Answer: C
Rationale: A respiratory rate of 24 breaths/min suggests fluid overload, a potential complication of IV fluids, possibly leading to pulmonary edema. Options A, B, and D are normal: blood pressure 130/80 mmHg, heart rate 88 bpm, and urine output 100 mL/hour indicate adequate hydration.
A postoperative client has a nasogastric (NG) tube following bowel surgery. The orders read, 'acetaminophen 650 PRN for fever above 101°F.' The client has a temperature of 101.4°F. What is the most appropriate nursing action?
- A. Administer the acetaminophen by rectal suppository.
- B. Administer the acetaminophen by elixir through the NG tube and turn suction off for 30 minutes.
- C. Administer the acetaminophen by crushing two tablets, giving it through the NG tube, and turning suction off for 30 minutes.
- D. Call the physician and question the order.
Correct Answer: A
Rationale: A rectal suppository is appropriate with an NG tube on suction, ensuring fever treatment without risking medication loss.
A client is admitted to a voluntary hospital mental health unit due to suicidal ideation. The client has been on the unit for 2 days and now states 'I demand to be released now!' The appropriate response from the nurse is
- A. You cannot be released because you are still suicidal.
- B. You can be released only if you sign a no suicide contract.
- C. Let's discuss your decision to leave and then we can prepare you for discharge.
- D. You have a right to sign out as soon as we get the provider's discharge order.
- E. Cbe released because you are still suicidal.
- F. You can be released only if you sign a no suicide contract.
Correct Answer: C
Rationale: Clients voluntarily admitted to the hospital have a right to demand and obtain release. Discussing the decision initially allows an opportunity for other interventions.
A client with acquired immunodeficiency syndrome (AIDS) is admitted with a tentative diagnosis of late AIDS dementia complex. The nursing assessment is most likely to reveal which of the following?
- A. Hyperactive deep tendon reflexes.
- B. Peripheral neuropathy affecting the hands.
- C. Disorientation to person, place, and time.
- D. Impaired concentration and memory loss.
Correct Answer: C
Rationale: approximately 65% of AIDS clients demonstrate a progressive dementia staged according to severity of debilitation; late stage is typified by cognitive confusion and disorientation
A client who has had an above-knee amputation (AKA) with an immediate prosthetic fitting.
It is MOST important for the nurse to
- A. assess drainage from Penrose drains.
- B. observe dressings for signs of excessive bleeding.
- C. elevate the stump for no less than 40 hours.
- D. provide cast care to the affected extremity.
Correct Answer: D
Rationale: Strategy: Answers are a mix of assessments and implementations. Is there an appropriate assessment? No. Determine the outcome of each implementation. (1) drains not usually used with amputations (2) rigid cast dressing frequently used to create a socket for prosthesis (3) elevation of extremity unnecessary, rigid cast dressing prevents swelling (4) correct-cast applied to provide uniform compression, prevent pain and contractures