Nokea
A client presents with a urine specific gravity of 1.018. What action should the nurse take?
- A. Evaluate the client's intake and output for the past 24 hours.
- B. Document the finding in the chart and continue to monitor.
- C. Obtain a specimen for a urine culture and sensitivity.
- D. Encourage the client to drink more fluids, especially water.
Correct Answer: B
Rationale: A urine specific gravity of 1.018 falls within the normal range, indicating adequate hydration. Therefore, the appropriate action is to document this finding in the client's chart and continue monitoring. There is no need to evaluate intake and output, as the specific gravity is normal. Obtaining a urine culture and sensitivity or encouraging increased fluid intake is unnecessary in this situation.
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A CD4+ lymphocyte count is performed on a client infected with HIV. The results of the test indicate a CD4+ count of 450 cells/L. The nurse interprets this test result as indicating:
- A. Improvement in the client
- B. The need for antiretroviral therapy
- C. The need to discontinue antiretroviral therapy
- D. An effective response to the treatment for HIV
Correct Answer: B
Rationale: A CD4+ count of 450 cells/L is below the normal range (500-1600 cells/mcL), indicating a decline in immune function in the client. Antiretroviral therapy is recommended when the CD4+ count falls below 500 cells/mcL or below 25%, or when the client displays symptoms of HIV. Therefore, the interpretation of this test result suggests that the client requires antiretroviral therapy to manage the HIV infection. Choices A, C, and D are incorrect because a CD4+ count of 450 cells/L does not signify improvement, discontinuation of therapy, or an effective response to treatment for HIV.
A client with stress incontinence is being taught about pelvic muscle exercises. Which statements should be included by the nurse? (Select all that apply.)
- A. Starting and stopping the urine stream involves using pelvic muscles.
- B. Tighten pelvic muscles for a slow count of 10 and then relax for a slow count of 10.
- C. Pelvic muscle exercises can be performed in various positions: lying down, sitting up, and standing.
- D. A & B
Correct Answer: D
Rationale: The correct statements to include when teaching a client with stress incontinence about pelvic muscle exercises are that starting and stopping the urine stream involve using pelvic muscles and that tightening pelvic muscles for a slow count of 10 and then relaxing for a slow count of 10 can help strengthen them. It is essential to highlight that pelvic muscle exercises can be performed in various positions, including lying down, sitting up, and standing. This variety in positions helps engage the muscles effectively. Performing these exercises 15 times in each position can aid in strengthening the pelvic floor muscles. Consistent exercise over several weeks typically leads to improved control over urine leakage. Choice C is incorrect because pelvic muscle exercises can be performed in different positions and are not limited to sitting upright with feet on the floor.
Why is the combination drug trimethoprim-sulfamethoxazole (TMP-SMX) necessary?
- A. To broaden the antibacterial spectrum.
- B. To decrease bacterial resistance.
- C. To improve the taste.
- D. To minimize toxic effects.
Correct Answer: B
Rationale: The correct answer is B: To decrease bacterial resistance. Trimethoprim-sulfamethoxazole (TMP-SMX) is a combination drug used to prevent bacterial resistance to sulfonamides. It works by targeting different steps in the bacterial metabolic pathway, making it harder for bacteria to develop resistance. Choice A is incorrect because the combination does not broaden the antibacterial spectrum; instead, it enhances effectiveness against specific bacteria. Choice C is incorrect as taste improvement is not the primary reason for combining these drugs. Choice D is incorrect because while combination therapy can sometimes help minimize toxic effects, the primary purpose in this case is to address bacterial resistance.
A nurse is assessing the status of a client with diabetes mellitus. The nurse concludes that the client is exhibiting adequate diabetic control if the serum level of glycosylated hemoglobin A1C (HbA1C) is less than:
- A. 7%
- B. 9%
- C. 10%
- D. 15%
Correct Answer: A
Rationale: The correct answer is A: 7%. Glycosylated hemoglobin A1C (HbA1C) level of 7.0% or less is considered indicative of adequate diabetic control. This level reflects good long-term blood sugar management. Choices B, C, and D are incorrect because an HbA1C level above 7% indicates poor diabetic control and an increased risk of complications associated with diabetes, such as cardiovascular disease, neuropathy, and retinopathy.
A client who is anxious about an impending surgery is at risk for respiratory alkalosis. For which signs and symptoms of respiratory alkalosis does the nurse assess this client?
- A. Disorientation and dyspnea
- B. Drowsiness, headache, and tachypnea
- C. Tachypnea, dizziness, and paresthesias
- D. Dysrhythmias and decreased respiratory rate and depth
Correct Answer: C
Rationale: The correct answer is C: Tachypnea, dizziness, and paresthesias. When a client is anxious, they may hyperventilate, leading to respiratory alkalosis. Tachypnea (rapid breathing) is a common sign of respiratory alkalosis. Dizziness and paresthesias (tingling or numbness in the extremities) are also typical symptoms. Choices A, B, and D are incorrect. Disorientation and dyspnea (Choice A) are not specific signs of respiratory alkalosis. Drowsiness, headache, and tachypnea (Choice B) may be more indicative of other conditions. Dysrhythmias and decreased respiratory rate and depth (Choice D) are not consistent with the expected signs of respiratory alkalosis.