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A client reports that he has been vomiting for three days, has a low-grade temperature, and feels lethargic. Which Ivanof the following nursing actions is MOST appropriate in evaluating for fluid volume deficit?
- A. Obtain a urinalysis for casts and specific gravity.
- B. Determine client's weight and assess gain or loss.
- C. Ask client to provide a 24-hour intake and output record.
- D. Determine the quality of the client's skin turgor.
Correct Answer: B
Rationale: daily weight is the best way to evaluate for fluid volume deficit
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The nurse is caring for a client who is receiving a continuous IV infusion of heparin. Which of the following laboratory results should the nurse report immediately?
- A. PTT of 90 seconds.
- B. INR of 1.0.
- C. Platelet count of 150,000/mm^3.
- D. Hemoglobin of 13 g/dL.
Correct Answer: A
Rationale: A PTT of 90 seconds is above the therapeutic range (60–80 seconds), increasing bleeding risk. Options B, C, and D are normal.
Which of the following nursing observations documented in the client's chart MOST clearly indicates the client's mood?
- A. Client states, 'I see snakes climbing on the walls at all times of the day.'
- B. Unable to sustain a train of thought for long periods of time during history-taking.
- C. Clenches her fists and shouts in an angry tone of voice when asked about family problems.
- D. Is unaware of where she is, what day and year it is, or what time it is.
Correct Answer: C
Rationale: gives data that reflect client's feelings, tone, and behavior associated with those feelings, as well as content area of conversation that evoked that mood
The nurse is caring for a client with a history of seizures. The client begins to experience a tonic-clonic seizure. Which of the following actions should the nurse take FIRST?
- A. Restrain the client to prevent injury.
- B. Place a tongue depressor in the client's mouth.
- C. Turn the client to the side.
- D. Administer lorazepam (Ativan) IV.
Correct Answer: C
Rationale: turning the client to the side helps maintain a patent airway and prevents aspiration during a seizure
A client reports that he has been vomiting for three days, has a low-grade temperature, and feels lethargic. Which of the following nursing actions is MOST appropriate in evaluating for fluid volume deficit?
- A. Obtain a urinalysis for casts and specific gravity.
- B. Determine client's weight and assess gain or loss.
- C. Ask client to provide a 24-hour intake and output record.
- D. Determine the quality of the client's skin turgor.
Correct Answer: B
Rationale: daily weight is the best way to evaluate for fluid volume deficit
The nurse is caring for a client who is receiving a continuous IV infusion of dopamine for hypotension. Which of the following findings would be of GREATest concern to the nurse?
- A. Heart rate of 100 bpm.
- B. Blood pressure of 90/60 mmHg.
- C. Urine output of 20 mL/hour.
- D. Respiratory rate of 18 breaths/min.
Correct Answer: C
Rationale: Urine output of 20 mL/hour indicates oliguria, a serious complication of dopamine, suggesting inadequate renal perfusion despite treatment for hypotension. Options A, B, and D are less concerning: heart rate 100 bpm and blood pressure 90/60 mmHg are expected, and respiratory rate 18 breaths/min is normal.