Nokea
A client has had vomiting and diarrhea for the past 3 days. Which of the following findings indicates the client is experiencing fluid volume deficit?
- A. Jugular vein distention
- B. Bradycardia
- C. Increased respiratory rate
- D. Bounding pulses
Correct Answer: C
Rationale: An increased respiratory rate is a sign of fluid volume deficit as the body attempts to compensate for decreased blood volume. Jugular vein distention, bradycardia, and bounding pulses are not typical findings of fluid volume deficit. Jugular vein distention is more commonly associated with fluid volume overload, bradycardia can be a sign of fluid volume excess or other issues, and bounding pulses are not typically seen in fluid volume deficit.
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A nurse is providing discharge teaching to a client who has a new prescription for metformin. Which of the following instructions should the nurse include?
- A. Take this medication at bedtime.
- B. You should expect your urine to turn orange while taking this medication.
- C. This medication can cause you to gain weight.
- D. Take this medication with food to reduce gastrointestinal discomfort.
Correct Answer: D
Rationale: The correct answer is D because taking metformin with food helps reduce gastrointestinal discomfort, a common side effect of the medication. Choice A is incorrect as metformin is usually taken with meals to minimize side effects. Choice B is incorrect because metformin does not typically cause urine discoloration. Choice C is incorrect as metformin is associated with weight loss or weight neutrality rather than weight gain.
A client has a new prescription for enoxaparin. Which of the following instructions should the nurse include?
- A. Take this medication with food to reduce stomach upset.
- B. Inject this medication into the muscle.
- C. Massage the injection site after administering the medication.
- D. Inject this medication into the abdomen.
Correct Answer: D
Rationale: The correct answer is D because enoxaparin should be injected into the abdomen to ensure proper absorption. Choice A is incorrect as enoxaparin should not be taken with food. Choice B is incorrect as enoxaparin should be injected subcutaneously, not into the muscle. Choice C is incorrect as massaging the injection site after administering enoxaparin is not recommended.
A nurse in a provider's office is reviewing the laboratory results of a group of clients. The nurse should identify that which of the following sexually transmitted infections is a nationally notifiable infectious disease that should be reported to the state health department?
- A. Chlamydia
- B. Human papillomavirus
- C. Candidiasis
- D. Herpes simplex virus
Correct Answer: A
Rationale: Chlamydia is the correct answer. It is a sexually transmitted infection that is nationally notifiable, meaning healthcare providers are required to report cases to the state health department. This is crucial for disease surveillance, monitoring, and implementing public health interventions. Human papillomavirus, Candidiasis, and Herpes simplex virus are not nationally notifiable infectious diseases and do not require mandatory reporting to the state health department.
A nurse is preparing to teach a client about the use of a peak flow meter. Which of the following instructions should the nurse include?
- A. Place the mouthpiece in your mouth and blow out as quickly as you can.
- B. Exhale slowly into the mouthpiece over 5 seconds.
- C. Take a slow deep breath before blowing into the mouthpiece.
- D. Blow into the mouthpiece at a steady rate for 3 seconds.
Correct Answer: A
Rationale: The correct instruction for using a peak flow meter is to place the mouthpiece in your mouth and blow out as quickly as you can. This action helps measure the peak expiratory flow of the client. Choice B is incorrect because exhaling slowly does not provide an accurate peak flow reading. Choice C is incorrect as taking a slow deep breath before blowing interferes with obtaining an accurate measurement. Choice D is incorrect as blowing at a steady rate for 3 seconds may not reflect the peak expiratory flow accurately.
A nurse is preparing to administer an intermittent enteral feeding to a client who has an NG tube. Which of the following actions should the nurse take?
- A. Heat the feeding to 105°F (40.6°C).
- B. Elevate the head of the bed to 45 degrees.
- C. Flush the tube with 0.9% sodium chloride.
- D. Verify the pH of the gastric aspirate.
Correct Answer: D
Rationale: Verifying the pH of the gastric aspirate is the correct action to take before administering an intermittent enteral feeding through an NG tube. This step ensures proper tube placement in the stomach, as the gastric aspirate should have an acidic pH (usually below 5). Heating the feeding solution, elevating the head of the bed, or flushing the tube with saline are not directly related to verifying tube placement and are not the immediate actions needed before administering the feeding.