Nokea
A client's admission urinalysis shows the specific gravity value of 1.039. Which of the following assessment data would the nurse expect to find when assessing this client?
- A. Moist mucous membranes
- B. Urinary frequency
- C. Poor skin turgor
- D. Increased blood pressure
Correct Answer: C
Rationale: Poor skin turgor. The specific gravity value is high, indicating dehydration. Poor skin turgor (tenting of the skin) is consistent with this problem.
You may also like to solve these questions
The nurse is collecting data from a 30-month-old client. Which of the following findings would require follow-up?
- A. head circumference has increased by 1 inch (2.5 cm) in the past year
- B. current weight is six times greater than birth weight
- C. nighttime bladder control has not been achieved
- D. anterior and posterior fontanels are both fused
Correct Answer: C
Rationale: Lack of nighttime bladder control at 30 months may indicate developmental delay or medical issues, requiring follow-up to assess for underlying causes.
A triage nurse has these 4 clients arrive in the emergency department within a 15 minute period. Which client should the triage nurse send back to be seen first?
- A. A 2 month old infant with a history of rolling off the bed and has bulging fontanels with crying
- B. A teenager who got a singed beard while camping
- C. An elderly client with complaints of frequent liquid brown colored stools
- D. A middle aged client with intermittent pain behind the right scapula
Correct Answer: B
Rationale: A teenager who got a singed beard while camping. This client is in the greatest danger with a potential of respiratory distress, Any client with singed facial hair has been exposed to heat or fire in close range that could have caused damage to the interior of the lung. Note that the interior lining of the lung has no nerve fibers so the client will not be aware of swelling.
The nurse is teaching parents about the treatment plan for a 2 weeks-old infant with Tetralogy of Fallot. While awaiting future surgery, the nurse instructs the parents to immediately report
- A. Loss of consciousness
- B. Feeding problems
- C. Poor weight gain
- D. Fatigue with crying
Correct Answer: A
Rationale: Loss of consciousness. This indicates anoxia, which may lead to death, requiring immediate reporting.
A client admitted with acute myocardial infarction suddenly displays air hunger, dyspnea, and coughing with frothy, pink-tinged sputum. What would the nurse anticipate when auscultating the breath sounds of this client?
- A. Bronchial breath sounds at lung periphery
- B. Clear vesicular breath sounds at lung bases
- C. Diffuse bilateral crackles at lung bases
- D. Stridor in upper airways
Correct Answer: C
Rationale: Frothy, pink-tinged sputum and dyspnea indicate pulmonary edema, a complication of myocardial infarction. Diffuse bilateral crackles are heard due to fluid in the alveoli.
The family of a young man who has been declared brain dead following an accident tells the nurse that the doctors said their son would be a good organ donor. They ask the nurse if donating his organs would mean that they could not have a regular funeral. Which response by the nurse is most accurate?
- A. Donating organs does deface the body, so a closed casket is necessary.
- B. Ask the physician which organs would be donated.
- C. Organ donation involves a surgical incision but should not interfere with any type of funeral.
- D. Donating organs is a wonderful service to humanity.
Correct Answer: C
Rationale: Organ donation involves surgical incisions but allows for open-casket funerals with proper preparation, addressing the family's concern accurately.