Nokea
A child has a nursing diagnosis of fluid volume excess related to compromised regulatory mechanisms. Which of the following nursing interventions is the most accurate measure to include in his care?
- A. Weigh the child twice daily on the same scale.
- B. Monitor intake and output.
- C. Check urine specific gravity of each voiding.
- D. Observe for edema.
Correct Answer: A
Rationale: Although all of these interventions are important aspects of care, weight is the most sensitive indicator of fluid balance. Although monitoring intake and output is important, weight is a more accurate indicator of fluid status. Urine specific gravity does not necessarily indicate fluid volume excess. Edema may not be apparent, yet the client may have fluid volume excess.
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A client is taking Deltasone (prednisone) each morning to treat his systemic lupus erythematosus. Which statement best explains the reason for taking the prednisone in the morning?
- A. There is less chance of forgetting the medication if taken in the morning.
- B. There will be less fluid retention if taken in the morning.
- C. The medication is absorbed best with the breakfast meal.
- D. Morning administration mimics the body's natural secretion of corticosteroid.
Correct Answer: D
Rationale: Prednisone is taken in the morning to mimic the body’s natural cortisol peak, which occurs early in the day, minimizing adrenal suppression and side effects. Timing does not primarily affect forgetting, fluid retention, or absorption.
The nurse notes variable decelerations on the fetal monitor strip. The most appropriate initial action would be to:
- A. Notify her doctor
- B. Start an IV
- C. Reposition the client
- D. Readjust the monitor
Correct Answer: C
Rationale: Variable decelerations are often caused by umbilical cord compression. Repositioning the client (e.g. to the left side) can relieve pressure on the cord and improve fetal oxygenation. Notifying the doctor or starting an IV are secondary if repositioning resolves the issue.
The nurse is preparing to check a client for Trousseau's sign. Which equipment should the nurse obtain?
- A. Tongue blade
- B. Blood pressure cuff
- C. Reflex hammer
- D. Stethoscope
Correct Answer: B
Rationale: Trousseau’s sign is elicited by inflating a blood pressure cuff on the arm to induce carpopedal spasm indicating hypocalcemia. The other equipment is not used for this assessment.
A client is admitted with sickle cell crises and sequestration. Upon assessing the client, the nurse would expect to find:
- A. Decreased blood pressure
- B. Moist mucus membranes
- C. Decreased respirations
- D. Increased blood pressure
Correct Answer: A
Rationale: Sickle cell crisis with sequestration can lead to hypovolemia due to blood pooling in organs, resulting in decreased blood pressure.
A client with a history of a kidney transplant is being discharged. The nurse should teach the client to:
- A. Avoid contact sports
- B. Eat a high-protein diet
- C. Limit fluid intake
- D. Take antibiotics daily
Correct Answer: A
Rationale: Contact sports risk trauma to the transplanted kidney, located in the pelvis, and should be avoided. High-protein diets, fluid limits, and daily antibiotics are not standard.