Nokea
A client who had a total hip replacement 2 days ago has developed an infection with a fever. The nursing diagnosis of fluid volume deficit related to diaphoresis is made. Which of the following is the most appropriate outcome?
- A. The client drinks 2,000 mL of fluid per day.
- B. The client understands how to manage the incision.
- C. The client's bed linens are changed as needed.
- D. The client's skin remains cool throughout hospitalization.
Correct Answer: A
Rationale: Drinking 2,000 mL of fluid daily addresses fluid volume deficit due to diaphoresis.
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A client has acute arterial occlusion. The physician has ordered a thrombolytic agent. Before starting the medication, the nurse should:
- A. Review the blood coagulation laboratory values
- B. Test the client's stools for occult blood
- C. Count the client's apical pulse for 1 minute
- D. Check the 24-hour urine output record
Correct Answer: A
Rationale: Before administering a thrombolytic agent for acute arterial occlusion, the nurse must review coagulation lab values (e.g., aPTT, INR, platelets) to assess bleeding risk, as thrombolytics increase hemorrhage potential. Stool testing, pulse counting, and urine output are secondary or unrelated.
A nurse is providing postmortem care for a client who has died of cancer. The most appropriate action is to:
- A. Remove all medical equipment immediately.
- B. Leave the body uncovered for family viewing.
- C. Bathe the body and position it respectfully.
- D. Notify the family to collect belongings quickly.
Correct Answer: C
Rationale: Bathing and positioning the body respectfully prepares it for family viewing and honors the deceased, aligning with postmortem care standards.
A client with acute renal failure reports shortness of breath. The nurse should:
- A. Administer oxygen.
- B. Increase fluid intake.
- C. Check lung sounds.
- D. Encourage coughing.
Correct Answer: C
Rationale: Shortness of breath may indicate fluid overload; lung sounds assess for pulmonary edema.
A client with acute renal failure has a low calcium level. The nurse should monitor for:
- A. Tetany.
- B. Hypertension.
- C. Bradycardia.
- D. Edema.
Correct Answer: A
Rationale: Low calcium can cause tetany, manifesting as muscle cramps or spasms.
The nurse is observing a client who is recovering from back strain lift a box as shown below. What should the nurse do?
- A. Praise the client for using correct body mechanics.
- B. Suggest to the client that she put both knees on the floor before attempting to lift the box.
- C. Advise the client to bend from the waist rather than stretching her back in this position.
- D. Inform the client that she should keep her back straight by squatting with both knees parallel.
Correct Answer: A
Rationale: The client is using correct body mechanics for lifting because she is keeping her back as straight as possible and is holding the box close to her body. She is using her large leg muscles to lift the box. She is using a broad base of support by placing her feet as wide apart as possible. The other suggestions would cause the client to put a strain on her back.