Nokea
A client has a history of oliguria, hypertension, and peripheral edema.
- A. Which nutrient should be restricted in a client with oliguria, hypertension, and peripheral edema (BUN 25, K+ 0 mEq/L)?
- B. Protein.
- C. Fats.
- D. Carbohydrates.
- E. Magnesium.
Correct Answer: A
Rationale: Oliguria, hypertension, and edema suggest renal impairment, where protein restriction reduces metabolic waste (e.g., urea nitrogen) that the kidneys cannot excrete. Fats and carbohydrates are encouraged, and magnesium restriction is not indicated.
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An extremely angry patient with bipolar illness who just learned his wife has filed for divorce.
Which of the following responses by the nurse is MOST appropriate?
- A. Allow the patient to use the phone.
- B. Confront the patient about his anger and inappropriate plan of action.
- C. Do not allow the patient to use the phone because he is an involuntary patient.
- D. Set limits on the patient's phone use because he has been unable to control his behavior.
Correct Answer: A
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) correct-patient is able to use phone unless otherwise indicated by court order or physician's order (2) has not lost civil right to use phone (3) denies patient his civil rights (4) inappropriate
If a very active two year-old client pulls his tunneled central venous catheter out, what initial nursing action is appropriate?
- A. Obtain emergency equipment
- B. Assess heart rate, rhythm and all pulses
- C. Apply pressure to the vessel insertion site
- D. Use cold packs at the exit incision site
Correct Answer: C
Rationale: If a central venous catheter is accidentally removed, pressure should be applied to the vein entry site to prevent bleeding and complications.
A two-day-old infant in the newborn nursery does not appear interested in taking formula from the mother or the nurse.
An appropriate nursing diagnosis is high risk for
- A. impaired swallowing.
- B. failure to thrive.
- C. fluid volume deficit.
- D. altered health maintenance.
Correct Answer: C
Rationale: Strategy: Think about each answer choice. (1) no information about swallowing provided with question (2) this is a medical diagnosis not a nursing diagnosis (3) correct-may become dehydrated (4) not specific for problem described
A client in the intensive care unit is overheard telling his wife, 'It's impossible to get any sleep in this place with all the noise and lights on all the time.' After talking with the client, the nurse determines that the client is bothered by sensory disturbance related to being in the ICU. Which laboratory finding would confirm the nurse's assessment of sensory disturbance?
- A. Increased urine catecholamines
- B. Decreased TSH
- C. Erratic changes in BUN levels
- D. Increased blood glucose levels
Correct Answer: A
Rationale: Sensory disturbance and stress in the ICU increase catecholamines (e.g., epinephrine), detectable in urine. Other labs are unrelated to sensory disturbance.
A client displaying the following symptoms: elevated vital signs, hallucinations, and aggressive behavior. The client's friend says she thinks that he has been using hallucinogenic drugs.
The appropriate nursing action would be to
- A. put the client in full restraints.
- B. decrease environmental stimulation.
- C. call the security guards.
- D. administer a PRN dose of chlorpromazine (Thorazine).
Correct Answer: B
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) unnecessary at this time (2) correct-symptoms will subside with time and decreased stimulation (3) unnecessary at this time (4) inappropriate