Nokea
A 70 year-old post-operative client has elevated serum BUN, HCT, Cl, and Na+. Creatinine and K+ are within normal limits. The nurse should perform additional assessments to confirm that an actual problem is:
- A. Impaired gas exchange
- B. Metabolic acidosis
- C. Renal insufficiency
- D. Fluid volume deficit
Correct Answer: D
Rationale: Fluid volume deficit. In fluid volume deficit, serum BUN, Na+, and hematocrit may be elevated secondary to hemoconcentration.
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The most important information for the nurse to have when planning care for the client with diabetes is the client's
- A. Family medical history
- B. Blood glucose history
- C. 24-hour dietary history
- D. Medical history
Correct Answer: B
Rationale: Answer B is correct. The most objective answer is the blood glucose history. Answers A, C, and D are more subjective. This information is reported data.
The nurse is caring for a frail elderly client in her home. Which behavior, if observed or reported, should the nurse report to the supervisor for further evaluation of possible abuse?
- A. The client's daughter is attempting to be declared her mother's legal guardian.
- B. The client is frequently left in bed alone in the house for several hours at a time.
- C. The client has brown spots on her arms.
- D. The client says, 'My daughter doesn't like me very much. She yells at me.'
Correct Answer: B
Rationale: Leaving a frail client alone for hours poses neglect risk, warranting abuse evaluation. Guardianship, brown spots, or yelling are less definitive without context.
The nurse is preparing to obtain a urine specimen for culture and sensitivity from a client who has an indwelling urinary catheter that was inserted 2 days ago. Which of the following actions should the nurse take?
- A. Attach a sterile syringe to the specimen port.
- B. Withdraw a sample of fluid from the balloon port.
- C. Empty urine from the urinary drainage bag into a specimen container.
- D. Collect all urine from the urinary drainage bag during a 24-hour period.
Correct Answer: A
Rationale: Using a sterile syringe at the specimen port (A) ensures a clean sample. Balloon port (B), drainage bag (C), or 24-hour collection (D) risk contamination.
The home health nurse visits a 72-year-old client with pneumonia who was discharged from the hospital 3 days ago. The client has less of a productive cough at night but now reports sharp chest pain with inspiration. Which finding is most important for the nurse to report to the supervising registered nurse?
- A. Bronchial breath sounds
- B. Increased tactile fremitus
- C. Low-pitched wheezing (rhonchi)
- D. Pleural friction rub
Correct Answer: D
Rationale: Pleural friction rub (D) indicates pleuritis or pleural effusion, a serious complication requiring immediate reporting. Other findings (A, B, C) are less specific or urgent.
The nurse is teaching about nonsteroidal anti-inflammatory drugs (NSAIDs) to a group of arthritic clients. To minimize the side effects, the nurse should emphasize which of the following actions?
- A. Reporting joint stiffness in the morning
- B. Taking the medication 1 hour before or 2 hours after meals
- C. Using alcohol in moderation unless driving
- D. Continuing to take aspirin for short term relief
Correct Answer: B
Rationale: Taking the medication 1 hour before or 2 hours after meals. Taking the medication 1 hour before or 2 hours after meals will result in a more rapid effect.