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A client with a diagnosis of hypothermia is being admitted to the hospital by a nurse. Which of the following signs does the nurse anticipate that this client will exhibit?
- A. Increased heart rate and increased blood pressure
- B. Increased heart rate and decreased blood pressure
- C. Decreased heart rate and increased blood pressure
- D. Decreased heart rate and decreased blood pressure
Correct Answer: D
Rationale: Hypothermia decreases the heart rate and blood pressure due to reduced metabolic needs of the body. With lower metabolic demands, the heart's workload decreases, leading to reductions in both heart rate and blood pressure. Choices A, B, and C are incorrect because hypothermia typically results in a decrease in heart rate and blood pressure, not an increase.
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A client recovering from extracorporeal shock wave lithotripsy for renal calculi has an ecchymotic area on the right lower back. What action should the nurse take?
- A. Administer fresh-frozen plasma.
- B. Apply an ice pack to the site.
- C. Place the client in the prone position.
- D. Obtain serum coagulation test results.
Correct Answer: B
Rationale: After extracorporeal shock wave lithotripsy, ecchymosis can occur due to bleeding into the tissues from the shock waves. Applying an ice pack helps reduce the extent and discomfort of bruising. Administering fresh-frozen plasma and obtaining coagulation test results are not necessary as ecchymosis after this procedure is common and does not indicate a bleeding disorder that requires immediate intervention. Placing the client in the prone position will not address the bleeding or bruising in this situation.
A nurse cares for adult clients who experience urge incontinence. For which client should the nurse plan a habit training program?
- A. A 78-year-old female who is confused
- B. A 65-year-old male with diabetes mellitus
- C. A 52-year-old female with kidney failure
- D. A 47-year-old male with arthritis
Correct Answer: A
Rationale: For a bladder training program to succeed in a client with urge incontinence, the client must be alert, aware, and able to resist the urge to urinate. Habit training will work best for a confused client. This includes going to the bathroom (or being assisted to the bathroom) at set times. The other clients may benefit from other types of bladder training. A confused client may need structured assistance to establish a regular bathroom routine, which can help manage urge incontinence effectively. Clients with diabetes mellitus, kidney failure, or arthritis may require different strategies tailored to their specific conditions.
A nurse reviews a female client's laboratory results. Which result from the client's urinalysis should the nurse recognize as abnormal?
- A. pH 5.6
- B. Ketone bodies present
- C. Specific gravity of 1.020
- D. Clear and yellow color
Correct Answer: B
Rationale: The correct answer is B: Ketone bodies present. Ketone bodies in urine indicate abnormal metabolism, specifically the incomplete breakdown of fatty acids. Normally, there should be no ketones present in urine. Ketone bodies are produced when the body uses fat sources instead of glucose for cellular energy. A pH range between 4.6 and 8, a specific gravity between 1.005 and 1.030, and clear yellow color in urine are considered normal findings for a female client's urinalysis. Therefore, options A, C, and D are within normal ranges and not indicative of abnormal results in the urinalysis.
A nurse checks the residual volume from a client's nasogastric tube feeding before administering an intermittent tube feeding and finds 35 mL of gastric contents. What should the nurse do before administering the prescribed 100 mL of formula to the client?
- A. Pour the residual volume into the nasogastric tube through a syringe with the plunger removed
- B. Discard the residual volume properly and record it as output on the client's fluid balance record
- C. Dilute the residual volume with water and inject it into the nasogastric tube, applying pressure on the plunger
- D. Mix the residual volume with the formula and pour it into the nasogastric tube, using a syringe without a plunger
Correct Answer: A
Rationale: After checking the residual feeding contents, the nurse should pour the residual volume back into the stomach by removing the syringe bulb or plunger and then pouring the gastric contents, using the syringe, into the nasogastric tube. This helps ensure that the residual volume is reintroduced into the client's gastrointestinal tract. Option B is incorrect because discarding the residual volume without reinstilling it into the stomach can lead to inaccurate medication administration and potential electrolyte imbalances. Option C is incorrect as diluting the residual volume with water and injecting it under pressure can cause aspiration or discomfort for the client. Option D is incorrect because mixing the residual volume with the formula can alter the prescribed dosage and consistency, potentially affecting the client's nutritional intake and causing complications.
A child who weighs 10 kg will begin taking oral trimethoprim-sulfamethoxazole (TMP-SMX). The liquid preparation contains 40 mg of TMP and 200 mg of SMX per 5 mL. The nurse determines that the child's dose should be 8 mg of TMP and 40 mg of SMX/kg/day divided into two doses. Which order for this child is correct?
- A. 5 mL PO BID
- B. 5 mL PO daily
- C. 10 mL PO BID
- D. 10 mL PO daily
Correct Answer: A
Rationale: The correct answer is A: '5 mL PO BID.' To calculate the child's daily dose requirement, you multiply the child's weight (10 kg) by the prescribed dosage per kg, which is 8 mg for TMP and 40 mg for SMX. This results in a total daily requirement of 80 mg of TMP and 400 mg of SMX. To divide this into two doses, each dose should contain half of the total daily requirement, which is 40 mg TMP and 200 mg SMX. Since the liquid preparation contains 40 mg of TMP and 200 mg of SMX per 5 mL, the correct dose per administration is 5 mL. Therefore, 5 mL PO BID is the correct order. Choice B, '5 mL PO daily,' is incorrect as the total daily dose needs to be divided into two doses. Choices C and D, '10 mL PO BID' and '10 mL PO daily,' respectively, are incorrect as they do not align with the calculated dosage requirements based on the child's weight and the prescribed dosage per kg.