Nokea
A client has been diagnosed with renal insufficiency, which has led to pronounced fluid volume excess. The nurse would expect which of the following signs and symptoms? Select all that apply.
- A. decreased urine output
- B. hypotension
- C. jugular vein distention
- D. weak, thready pulse
- E. tachycardia
Correct Answer: A,C,E
Rationale: Renal insufficiency causes fluid retention, leading to decreased urine output, jugular vein distention, and tachycardia (compensatory response). Hypotension and weak pulse are more typical of fluid volume deficit.
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The nurse is caring for an infant following a cleft lip repair. While comforting the infant, the nurse should avoid:
- A. Holding the infant
- B. Offering a pacifier
- C. Providing a mobile
- D. Offering sterile water
Correct Answer: B
Rationale: Offering a pacifier is contraindicated after cleft lip repair as it can disrupt the surgical site and impair healing.
A client who is to undergo electroconvulsive therapy for severe depression is quite anxious about the treatment and asks the nurse what to expect after treatment. Which of the following information should the nurse include? Select all that apply.
- A. The client will experience confusion for a short time.
- B. Headache and muscle soreness are common.
- C. Some degree of memory loss, usually transient, may occur.
- D. Possible urinary incontinence may occur for 12 hours.
- E. The client may experience hallucinations for 2 to 3 weeks.
Correct Answer: A,B,C
Rationale: ECT causes short-term confusion (A), headache/muscle soreness (B), and transient memory loss (C). Incontinence (D) and prolonged hallucinations (E) are not typical.
A 60-year-old diabetic is taking glyburide (Diabeta) 1.25 mg daily to treat Type II diabetes mellitus. Which statement indicates the need for further teaching?
- A. I will keep candy with me just in case my blood sugar drops.
- B. I need to stay out of the sun as much as possible.
- C. I often skip dinner because I don't feel hungry.
- D. I always wear my medical identification.
Correct Answer: C
Rationale: Skipping meals while on glyburide increases hypoglycemia risk, indicating a need for further teaching.
A client with Lyme's disease is being treated with Achromycin (tetracycline HCl). The nurse should tell the client that the medication will be rendered ineffective if taken with:
- A. Antacids
- B. Salicylates
- C. Antihistamines
- D. Sedative-hypnotics
Correct Answer: A
Rationale: Antacids containing calcium, magnesium, or aluminum can bind tetracycline, reducing its absorption and effectiveness.
The mother of a child with chickenpox wants to know if there is a medication that will shorten the course of the illness. Which medication is sometimes used to speed healing of the lesions and shorten the duration of fever and itching?
- A. Zovirax (acyclovir)
- B. Varivax (varicella vaccine)
- C. VZIG (varicella-zoster immune globulin)
- D. Periactin (cyproheptadine)
Correct Answer: A
Rationale: Acyclovir can reduce the severity and duration of chickenpox symptoms if started early, particularly in high-risk patients.