Nokea
A fluid challenge of 250 cc of normal saline infused over 15 min is ordered for a client with possible acute renal failure. The nurse understands that the fluid challenge is given to
- A. rule out dehydration as the cause of oliguria.
- B. increase cardiac output and fluid volume.
- C. promote the transfer of intravascular fluid to the intracellular space.
- D. dilute the level of waste products in the intravascular fluid.
Correct Answer: A
Rationale: expected response after a fluid challenge on normally functioning kidneys is an increase in urine output; will occur if low urine output is due to dehydration; if it is due to acute renal failure, there will continue to be oliguria
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The nurse is caring for a client with a history of type 1 diabetes who is receiving insulin lispro (Humalog) 8 units before meals. Which of the following symptoms should the nurse report immediately?
- A. Mild fatigue.
- B. Sweating and confusion.
- C. Occasional thirst.
- D. Mild headache.
Correct Answer: B
Rationale: Sweating and confusion indicate hypoglycemia, a medical emergency with insulin lispro. Options A, C, and D are less urgent.
A nurse arranges for a interpreter to facilitate communication between the health care team and a non-English speaking client. To promote therapeutic communication, the appropriate action for the nurse to remember when working with an interpreter is to
- A. promote verbal and nonverbal communication with both the client and the interpreter
- B. speak only a few sentences at a time and then pause for a few moments
- C. plan that the encounter will take more time than if the client spoke English
- D. ask the client to speak slowly and to look at the person spoken to
Correct Answer: A
Rationale: The nurse should communicate with the client and the family, not with the interpreter. Culturally appropriate eye contact, gestures, and body language toward the client and family are important factors to enhance rapport and understanding. Maintain eye contact with both the client and interpreter to elicit feedback and read nonverbal cues.
The nurse is caring for a client with a history of bipolar disorder.
- A. Which client statement indicates a need for further teaching about lithium therapy?
- B. I’ll drink plenty of water every day.'
- C. I’ll have my blood levels checked regularly.'
- D. I can stop the medication if I feel better.'
- E. I’ll avoid eating foods high in sodium.'
Correct Answer: C
Rationale: Stating that the medication can be stopped when feeling better indicates a misunderstanding, as lithium requires consistent use to maintain therapeutic levels and prevent mood swings. Hydration, blood monitoring, and sodium awareness are correct.
When caring for a client with myasthenia gravis, an important nursing consideration would be to
- A. prevent accidents from falls as a result of vertigo.
- B. maintain fluid and electrolyte balance.
- C. control situations that could increase intracranial pressure and cerebral edema.
- D. assess muscle groups toward the end of the day.
Correct Answer: D
Rationale: client has increased muscle fatigue, needs more assistance toward end of day
Which of the following snacks would be suitable for a child with gluten-induced enteropathy?
- A. A soft oatmeal cookie
- B. Buttered popcorn
- C. A peanut butter and jelly sandwich
- D. Cheese pizza
Correct Answer: B
Rationale: Buttered popcorn is gluten-free, making it suitable for a child with celiac disease (gluten-induced enteropathy). The other options contain gluten.