Nokea
A client needs a 24-hour urine collection initiated. Which of the following client statements indicates an understanding of the procedure?
- A. I had a bowel movement, but I was able to save the urine.
- B. I have a specimen in the bathroom from about 30 minutes ago.
- C. I flushed what I urinated at 7 am and have saved the rest since.
- D. I drink a lot, so I will fill up the bottle and complete the test quickly.
Correct Answer: C
Rationale: Choice C is correct because it demonstrates the client's understanding of the procedure, which involves discarding the first urine of the day at the specified time and then saving all subsequent urine for the next 24 hours. Choices A, B, and D do not reflect an understanding of the correct procedure. Choice A is incorrect because bowel movements are not part of a 24-hour urine collection. Choice B is incorrect as it does not specify discarding the first urine. Choice D is incorrect as it mentions filling up the bottle quickly, which is not the correct way to collect a 24-hour urine sample.
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Which of the following is the best intervention for managing dehydration?
- A. Administer antiemetics to prevent nausea
- B. Monitor fluid and electrolyte levels
- C. Encourage the client to drink more fluids
- D. Administer intravenous fluids
Correct Answer: B
Rationale: The best intervention for managing dehydration is to monitor fluid and electrolyte levels. This approach allows healthcare providers to assess the severity of dehydration, determine appropriate fluid replacement therapy, and prevent complications. Administering antiemetics (Choice A) may help with nausea but does not address the underlying issue of dehydration. Encouraging the client to drink more fluids (Choice C) may be appropriate for mild dehydration but can be inadequate for moderate to severe cases. Administering intravenous fluids (Choice D) is crucial for severe dehydration or cases where oral rehydration is ineffective, but monitoring fluid and electrolyte levels should precede this intervention.
A nurse is teaching a client who has chronic obstructive pulmonary disease (COPD) about breathing exercises. Which of the following instructions should the nurse include?
- A. Use abdominal breathing during physical activity
- B. Inhale quickly and deeply through the nose
- C. Use pursed-lip breathing during physical activity
- D. Breathe quickly and deeply during exercise
Correct Answer: C
Rationale: The correct answer is C: 'Use pursed-lip breathing during physical activity.' Pursed-lip breathing is a beneficial technique for clients with COPD as it helps improve airflow by keeping the airways open longer. Choice A is incorrect as abdominal breathing may not be as effective in COPD as pursed-lip breathing. Choice B, inhaling quickly and deeply through the nose, is not recommended as it can lead to hyperventilation. Choice D, breathing quickly and deeply during exercise, is also not suitable for clients with COPD as it can cause increased shortness of breath.
How should a healthcare provider assess and manage a patient with anemia?
- A. Monitor hemoglobin levels and provide iron supplements
- B. Administer B12 injections
- C. Monitor for signs of infection and administer folic acid
- D. Administer oxygen therapy
Correct Answer: A
Rationale: Corrected Question: To assess and manage a patient with anemia, monitoring hemoglobin levels and providing iron supplements are crucial. Anemia is commonly caused by iron deficiency, making iron supplementation a cornerstone of treatment. B12 injections (Choice B) are more relevant for treating megaloblastic anemia, not the typical iron-deficiency anemia. Monitoring for signs of infection and administering folic acid (Choice C) are important in specific types of anemia like megaloblastic anemia, but not the first-line approach for anemia management. Administering oxygen therapy (Choice D) is not the primary intervention for anemia unless severe hypoxemia is present, which is not typically seen in anemia.
The nurse is supervising the staff providing care for an 18-month-old hospitalized with hepatitis A. The nurse determines that the staff's care is appropriate if which of the following is observed?
- A. The child is placed in a private room
- B. The staff removes a toy from the child's bed and takes it to the nurse's station
- C. The staff offers the child french fries and a vanilla milkshake for a midafternoon snack
- D. The staff uses standard precautions
Correct Answer: A
Rationale: The correct answer is A. Private room placement is crucial when caring for a patient with hepatitis A to prevent the transmission of the disease to others. Placing the child in a private room helps contain the infection and protect other patients and staff. Choices B, C, and D are incorrect because removing a toy from the child's bed, offering specific snacks, or using standard precautions, while important in general care, are not specific measures required to prevent the spread of hepatitis A.
A client with moderate anxiety disorder is being taught stress management techniques by a nurse. Which response by the client indicates an understanding of the teaching?
- A. I will take a walk to reduce my anxiety
- B. I will imagine myself in a calm place when I can't concentrate
- C. I will meditate every other week
- D. I will cut back on my caffeine intake
Correct Answer: B
Rationale: The correct answer is B because imagining oneself in a calm place is a relaxation technique that helps reduce anxiety. Walking, meditating every other week, or cutting back on caffeine intake may have their benefits, but they are not as directly related to the immediate management of anxiety as the visualization technique described in option B.