Nokea
A client is being treated with I.V. fluids for hypovolemic shock. Which of the following values is the best indicator that fluid resuscitation has been effective?
- A. Urine output of 30 mL/hour.
- B. Systolic blood pressure of 90 mm Hg.
- C. Respiratory rate of 22 breaths/minute.
- D. Pulse rate of 110 bpm.
Correct Answer: A
Rationale: A urine output of 30 mL/hour indicates adequate renal perfusion, a key sign of effective fluid resuscitation in hypovolemic shock.
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The nurse is planning a continuous quality improvement (CQI) process to decrease the infection rate on the nursing unit. The nurse should consider which of the following when planning the process? Select all that apply.
- A. CQI processes are required by accrediting agencies
- B. The approach to CQI can be retrospective or concurrent
- C. Institutional Review Board (IRB) approval is required
- D. CQI is conducted by people who are not part of the process
- E. The CQI process has a fixed endpoint
Correct Answer: A,B
Rationale: CQI is often required by accrediting agencies and can be retrospective or concurrent. IRB approval is not typically needed, CQI involves unit staff, and it is ongoing without a fixed endpoint.
The nurse is caring for a client with a history of epilepsy who is prescribed valproic acid (Depakene). Which of the following laboratory tests should the nurse monitor?
- A. Liver function tests.
- B. Renal function tests.
- C. Complete blood count.
- D. Blood glucose levels.
Correct Answer: A
Rationale: Valproic acid can cause hepatotoxicity, requiring regular monitoring of liver function tests.
Which of the following characteristics should the nurse include in the teaching plan for a multiparous client after delivering a neonate diagnosed with trisomy 13?
- A. Webbed neck
- B. Small testes
- C. Congenital heart defects
- D. Polydactyly
Correct Answer: C
Rationale: Trisomy 13 is commonly associated with congenital heart defects. Webbed neck is more typical of Turner syndrome, and small testes or polydactyly are less specific to trisomy 13.
A 6-year-old child has had heart surgery to repair tetralogy of Fallot. When developing the discharge plan, the nurse should include information about:
- A. Allowing the child to lead a normal, active life.
- B. Persuading the child to get enough rest.
- C. Having the child develop postoperative complications.
- D. Having the child out of school for a month.
Correct Answer: A
Rationale: After tetralogy of Fallot repair, children can often lead a normal, active life with appropriate follow-up.
The nurse is caring for a client who has just undergone a pacemaker insertion. Which of the following instructions should the nurse include in the discharge teaching?
- A. Avoid lifting heavy objects for 4-6 weeks.
- B. Resume driving immediately.
- C. Use a microwave oven without restrictions.
- D. Avoid cell phone use permanently.
Correct Answer: A
Rationale: Avoiding heavy lifting for 4-6 weeks prevents dislodgement of the pacemaker leads during healing.