Nokea
A client's urinalysis results show a urine osmolality of 1200 mOsm/L. What action should the nurse take?
- A. Encourage the client to drink more fluids.
- B. Contact the provider and recommend a low-sodium diet.
- C. Prepare to administer an intravenous diuretic.
- D. Obtain a suction device and implement seizure precautions.
Correct Answer: A
Rationale: The correct action for the nurse to take when the client has a urine osmolality of 1200 mOsm/L, indicating dehydration, is to encourage the client to drink more fluids. Dehydration can lead to elevated urine osmolality, and increasing fluid intake can help rehydrate the client. A low-sodium diet is not the priority in this scenario as it would not directly address the dehydration indicated by the high urine osmolality. Administering an intravenous diuretic would further concentrate the urine, exacerbating the dehydration. Obtaining a suction device and implementing seizure precautions are not indicated based on the client's urine osmolality results and would not address the underlying issue of dehydration.
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A client is being taught about self-catheterization in the home setting. Which statements should the nurse include in this client's teaching? (Select all that apply.)
- A. Wash your hands before and after self-catheterization.
- B. Use lubricant on the tip of the catheter before insertion.
- C. A & B
- D. Self-catheterize at least twice a day or every 12 hours.
Correct Answer: C
Rationale: In teaching a client about self-catheterization, it is essential to emphasize proper hand hygiene before and after the procedure to prevent infections. Using lubricant on the catheter helps with insertion and reduces discomfort. Therefore, statements A and B are correct and should be included in the client's teaching. Option D is incorrect because self-catheterization frequency should be individualized based on the client's needs, and a specific time frame like every 12 hours may not be suitable for everyone. Choosing a smaller lumen catheter is preferred over a larger one. Self-catheterization should not be limited to a specific time frame but should be based on the individual's needs and voiding patterns. Therefore, option C is the correct choice as it includes the two essential statements for teaching self-catheterization in the home setting.
A nurse is assessing the status of a client with diabetes mellitus. The nurse concludes that the client is exhibiting adequate diabetic control if the serum level of glycosylated hemoglobin A1C (HbA1C) is less than:
- A. 7%
- B. 9%
- C. 10%
- D. 15%
Correct Answer: A
Rationale: The correct answer is A: 7%. Glycosylated hemoglobin A1C (HbA1C) level of 7.0% or less is considered indicative of adequate diabetic control. This level reflects good long-term blood sugar management. Choices B, C, and D are incorrect because an HbA1C level above 7% indicates poor diabetic control and an increased risk of complications associated with diabetes, such as cardiovascular disease, neuropathy, and retinopathy.
A patient has a serum potassium level of 2.7 mEq/L. The patient's provider has determined that the patient will need 200 mEq of potassium to replace serum losses. How will the nurse caring for this patient expect to administer the potassium?
- A. As a single-dose 200 mEq oral tablet
- B. As an intravenous bolus over 15 to 20 minutes
- C. In an intravenous solution at a rate of 10 mEq/hour
- D. In an intravenous solution at a rate of 45 mEq/hour
Correct Answer: C
Rationale: For a patient with severe hypokalemia with a serum potassium level of 2.7 mEq/L requiring 200 mEq of potassium replacement, the appropriate route of administration would be intravenous. Potassium chloride should be administered slowly to prevent adverse effects; therefore, the correct option is to administer the potassium in an intravenous solution at a rate of 10 mEq/hour. Choices A and B are incorrect because potassium should not be given as a single-dose oral tablet or as an intravenous bolus over a short period of time due to the risk of adverse effects. Choice D is also incorrect as the rate of 45 mEq/hour exceeds the recommended maximum infusion rate for adults with a serum potassium level greater than 2.5 mEq/L, which is 10 mEq/hour.
A CD4+ lymphocyte count is performed on a client infected with HIV. The results of the test indicate a CD4+ count of 450 cells/L. The nurse interprets this test result as indicating:
- A. Improvement in the client
- B. The need for antiretroviral therapy
- C. The need to discontinue antiretroviral therapy
- D. An effective response to the treatment for HIV
Correct Answer: B
Rationale: A CD4+ count of 450 cells/L is below the normal range (500-1600 cells/mcL), indicating a decline in immune function in the client. Antiretroviral therapy is recommended when the CD4+ count falls below 500 cells/mcL or below 25%, or when the client displays symptoms of HIV. Therefore, the interpretation of this test result suggests that the client requires antiretroviral therapy to manage the HIV infection. Choices A, C, and D are incorrect because a CD4+ count of 450 cells/L does not signify improvement, discontinuation of therapy, or an effective response to treatment for HIV.
A client is recovering from a closed percutaneous kidney biopsy and reports increased pain from 3 to 10 on a scale of 0 to 10. Which action should the nurse take first?
- A. Reposition the client on the operative side.
- B. Administer the prescribed opioid analgesic.
- C. Assess the pulse rate and blood pressure.
- D. Examine the color of the client's urine.
Correct Answer: C
Rationale: An abrupt increase in pain following a percutaneous kidney biopsy may indicate internal hemorrhage. Assessing the client's pulse rate and blood pressure is crucial as changes in vital signs can be indicative of hemorrhage. This assessment is essential in determining the client's hemodynamic status and the need for immediate intervention. Repositioning the client, administering pain medication, or checking urine color are not the priority actions in this situation and may delay necessary interventions for potential hemorrhage.