Nokea
A client with fluid volume excess has gained 6.6 pounds. The nurse recognizes that this is equivalent to what volume of fluid?
- A. Two liters.
- B. Three liters.
- C. Four liters.
- D. Five liters.
Correct Answer: B
Rationale: A weight gain of 6.6 pounds is approximately equivalent to 3 liters of fluid. It is important to remember that 1 liter of fluid is equal to 1 kg, which is approximately 2.2 pounds. Therefore, when the client gains 6.6 pounds, it translates to 3 liters of fluid. Choices A, C, and D are incorrect as they do not align with the conversion rate of 1 liter of fluid to 2.2 pounds.
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Which nursing diagnosis should be selected for a client who is receiving thrombolytic infusions for treatment of an acute myocardial infarction?
- A. Risk for infection related to thrombolysis.
- B. Risk for fluid volume deficit related to thrombolysis.
- C. Risk for impaired skin integrity related to thrombolysis.
- D. Risk for injury related to effects of thrombolysis.
Correct Answer: D
Rationale: Thrombolytic therapy increases the risk of bleeding, not infection, fluid volume deficit, or impaired skin integrity. The most significant concern with thrombolytic therapy is the potential for bleeding complications, which can lead to various injuries. Therefore, 'Risk for injury related to effects of thrombolysis' is the most appropriate nursing diagnosis in this scenario. Choices A, B, and C are incorrect as they do not directly correlate with the primary risk associated with thrombolytic therapy.
A client who has a history of unstable angina is admitted to the emergency department with chest pain.
- A. Chest pain relieved by rest.
- B. Chest pain unrelieved after taking 3 sequential nitroglycerin tablets.
- C. Chest pain occurring only with exertion.
- D. Chest pain lasting less than 5 minutes.
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A client with deep vein thrombosis (DVT) is receiving heparin therapy. Which laboratory test should the nurse monitor to evaluate the effectiveness of the heparin?
- A. Complete blood count (CBC)
- B. Activated partial thromboplastin time (aPTT)
- C. Prothrombin time (PT)
- D. International normalized ratio (INR)
Correct Answer: B
Rationale: The correct answer is B: Activated partial thromboplastin time (aPTT). This test is used to monitor the effectiveness of heparin therapy. A complete blood count (CBC) (choice A) is not specific for monitoring heparin therapy. Prothrombin time (PT) (choice C) and International normalized ratio (INR) (choice D) are more commonly used to monitor warfarin therapy, not heparin.
Which nursing problem has the highest priority when planning care for a client with Meniere's disease?
- A. Potential for injury related to vertigo.
- B. Alteration in comfort due to ear pain.
- C. Impaired skin integrity due to immobility.
- D. Anxiety due to fear of falling.
Correct Answer: A
Rationale: The correct answer is A. When caring for a client with Meniere's disease, the highest priority nursing problem is the potential for injury related to vertigo. Meniere's disease is characterized by symptoms like vertigo, which can increase the risk of falls and injuries. Ensuring the client's safety and preventing falls take precedence over other concerns. Choices B, C, and D are not the highest priority because they do not directly address the immediate risk of harm associated with vertigo and falls.
When speaking to young parents, the nurse states that lead poisoning is one of the most common preventable health problems affecting children. What condition occurs when the level of lead ingested exceeds the amount that can be absorbed by the bone?
- A. Malnutrition
- B. Anemia
- C. Bone pain
- D. Diarrhea
Correct Answer: B
Rationale: The correct answer is B: Anemia. When the amount of lead ingested exceeds the amount that can be absorbed by the bone, it leads to anemia. Malnutrition (Choice A) is a state of inadequate nutrition, not directly related to lead poisoning. Bone pain (Choice C) is a symptom of lead poisoning due to its effects on bones but not directly related to lead ingestion exceeding absorption. Diarrhea (Choice D) is not a direct consequence of lead ingestion exceeding absorption by bones.