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A client diagnosed with acute glomerulonephritis has pitting edema in the lower extremities, a blood pressure of 170/80 mm Hg, and proteinuria. When the practical nurse is assisting in the development of a care plan for this client, which measurement is the most accurate indicator of fluid loss or gain and should therefore be included in the plan?
- A. Blood pressure measurements
- B. Daily weight measurements
- C. Severity of pitting edema
- D. Strict intake and output measurements
Correct Answer: B
Rationale: Daily weights (B) are the most accurate for tracking fluid balance in glomerulonephritis. Blood pressure (A), edema (C), and intake/output (D) are less precise.
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In a long term rehabilitation care unit, a client with spinal cord injury complains of a pounding headache. The client is sitting in a wheelchair watching television. Further assessment by the nurse reveals excessive sweating, a splotchy rash, pilomotor erection, facial flushing, congested nasal passages and a heart rate of 50. The nurse should perform which action next?
- A. Take the client's respirations, blood pressure (BP), temperature and then pupillary responses
- B. Place the client into the bed and administer the ordered PRN analgesic
- C. Check the client for bladder distention and the client's urinary catheter for kinks
- D. Turn the television off and then assist client to use relaxation techniques
Correct Answer: C
Rationale: Check the client for bladder distention and the client's urinary catheter for kinks. These are findings of autonomic dysreflexia, typically initiated by a noxious stimulus below the level of injury such as a full bladder.
The nurse is assessing a young child at a clinic visit for a mild respiratory infection. Koplik spots are noted on the oral mucous membranes. The nurse should then assess which area of the body?
- A. The skin
- B. The lungs
- C. The muscles
- D. Bowel and bladder
Correct Answer: A
Rationale: The skin. A characteristic sign of rubeola is Koplik spots (small red spots with a bluish white center). These are found on the buccal mucosa about 2 days before and after the onset of the measles rash.
The nurse administers cimetidine (Tagamet) to a 79 year-old male with a gastric ulcer. Which parameter may be affected by this drug, and should be closely monitored by the nurse?
- A. Blood pressure
- B. Liver function
- C. Mental status
- D. Hemoglobin
Correct Answer: C
Rationale: The elderly are at risk for developing confusion when taking cimetidine, a drug that interacts with many other medications.
The nurse preceptor observes a graduate practical nurse collecting a urine sample for urinalysis and culture as pictured in the exhibit. What is the preceptor's best action?
- A. Advise the graduate nurse to discard the collected urine specimen and record the output
- B. Advise the graduate nurse to use a sterile specimen cup rather than a graduated container for collection
- C. Explain to the graduate nurse that midstream clean catch or straight catheterization is required
- D. Remind the graduate nurse that the specimen should be kept cool until it is sent to the laboratory
Correct Answer: C
Rationale: Urine for culture requires a midstream clean catch or catheterization (C) to avoid contamination. A graduated container (B) is acceptable if sterile. Discarding (A) is unnecessary, and cooling (D) is secondary.
A nurse is participating in an obstetrical emergency simulation in which the health care provider announces shoulder dystocia. Which of the following interventions should the assisting nurse implement?
- A. Assist maternal pushing efforts by applying fundal pressure during each contraction
- B. Document the time the fetal head was born
- C. Flex the client's legs back against the abdomen and apply downward pressure above the symphysis pubis
- D. Prepare for a forceps-assisted birth
- E. Request additional assistance from other nurses immediately
Correct Answer: C,E
Rationale: Shoulder dystocia requires urgent interventions like the McRoberts maneuver (flexing legs back, C) and suprapubic pressure (C) to dislodge the fetal shoulder. Additional assistance (E) is critical. Fundal pressure (A) can worsen impaction. Documentation (B) is secondary to immediate action. Forceps (D) are not typically used for shoulder dystocia.