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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When a client with dementia frequently becomes agitated, what should the nurse prioritize investigating?
- A. Fluid and electrolyte imbalances
- B. Medication history
- C. Environmental factors
- D. Cognitive functioning
Correct Answer: B
Rationale: The correct answer is to prioritize investigating the client's medication history. This is important because certain medications can contribute to agitation in clients with dementia. Understanding the medication history can help identify potential causes of agitation and guide appropriate interventions. Checking for fluid and electrolyte imbalances is important in healthcare but may not directly relate to the client's agitation. While environmental factors can influence behavior, investigating the medication history is more pertinent in this case. Cognitive functioning assessment is crucial in dementia care but may not be the priority when addressing acute agitation.
A nurse is collecting data from a client who has Tourette syndrome. The client reports taking haloperidol 0.5 mL orally three times a day at home. Which of the following components of the prescription should the nurse question?
- A. Frequency
- B. Dosage
- C. Timing of doses
- D. Route
Correct Answer: B
Rationale: The nurse should question the dosage of haloperidol as it is typically administered in milligrams (mg) and not milliliters (mL). The dosage should be expressed in a standardized unit for accuracy and to prevent medication errors. Frequency, timing of doses, and route are also important components of a prescription, but in this case, the nurse should focus on the unusual dosage form.
How should a healthcare professional assess a patient with hyperkalemia?
- A. Monitor ECG and administer insulin
- B. Monitor blood glucose levels and provide fluids
- C. Monitor for muscle weakness and administer calcium gluconate
- D. Monitor electrolyte levels and provide potassium supplements
Correct Answer: A
Rationale: Corrected Question: When assessing a patient with hyperkalemia, monitoring the ECG and administering insulin are crucial steps. Hyperkalemia can affect the heart's function, leading to life-threatening arrhythmias. Monitoring the ECG helps in identifying any cardiac abnormalities associated with high potassium levels. Administering insulin, along with glucose, helps shift potassium from the bloodstream into the cells, temporarily lowering the potassium levels.
Choice B is incorrect because monitoring blood glucose levels and providing fluids are not the primary interventions for hyperkalemia.
Choice C is incorrect as monitoring for muscle weakness and administering calcium gluconate are not the first-line treatments for hyperkalemia. Calcium gluconate may be used in specific situations to stabilize cardiac cell membranes in severe cases of hyperkalemia.
Choice D is incorrect because monitoring electrolyte levels and providing potassium supplements would worsen hyperkalemia, as the patient already has elevated potassium levels and does not require additional potassium supplementation.
A nurse is caring for a client who is at 41 weeks of gestation and is receiving oxytocin for labor induction. The nurse notes early decelerations on the fetal heart rate monitor. Which of the following nursing actions should the nurse take?
- A. Continue to monitor the fetal heart rate.
- B. Stop the oxytocin infusion.
- C. Perform a vaginal examination.
- D. Initiate an amnioinfusion.
Correct Answer: A
Rationale: The correct action for early decelerations, which are caused by fetal head compression and are considered normal during labor, is to continue monitoring the fetal heart rate. Early decelerations mirror contractions and usually do not require any intervention. Stopping the oxytocin infusion (Choice B) is not necessary as early decelerations are not typically a cause for concern related to oxytocin. Performing a vaginal examination (Choice C) or initiating an amnioinfusion (Choice D) are unnecessary and not indicated specifically for early decelerations.
A nurse is instructing a group of nursing students about the responsibilities involved with organ donation and procurement. When the nurse explains that all clients waiting for a kidney transplant have to meet the same qualifications, the students should understand that this aspect of care delivery is an example of which ethical principle?
- A. Fidelity
- B. Autonomy
- C. Justice
- D. Non-maleficence
Correct Answer: C
Rationale: The correct answer is C: Justice. Justice in healthcare ethics refers to fairness and equality in the distribution of resources and treatments. In this scenario, ensuring that all clients waiting for a kidney transplant meet the same qualifications demonstrates the ethical principle of justice by providing equal opportunities for all candidates. Choice A, fidelity, pertains to keeping promises and being faithful to agreements, which is not the primary ethical principle at play in this situation. Autonomy, choice B, relates to respecting a patient's right to make their own decisions, which is not directly applicable in the context of organ transplant qualifications. Non-maleficence, choice D, refers to the principle of doing no harm, which is important but not the primary ethical principle highlighted in this scenario.