Nokea
A nurse collaborates with an unlicensed assistive personnel (UAP) to provide care for a client who is prescribed a 24-hour urine specimen collection. Which statement should the nurse include when delegating this activity to the UAP?
- A. Void the clients first void and collect urine for 24 hours.
- B. Add the preservative to the container at the end of the test.
- C. Start the collection by saving the first urine of the morning.
- D. Ensure the client drinks plenty of water during collection.
Correct Answer: A
Rationale: The 24-hour urine collection begins after discarding the first void to ensure a full 24-hour period of collection. This ensures accurate measurement of excreted substances.
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A nurse assesses a client who is prescribed a medication that stimulates beta1 receptors. Which assessment finding should alert the nurse to urgently contact the health care provider?
- A. Heart rate of 50 beats/min
- B. Respiratory rate of 18 breaths/min
- C. Oxygen saturation of 92%
- D. Blood pressure of 144/69 mm Hg
Correct Answer: A
Rationale: Stimulation of beta1 receptor sites in the heart has positive chronotropic and inotropic actions, leading to an increased heart rate and cardiac output. A heart rate of 50 beats/min indicates the client is not responding to the medication, which is a cause for concern.
A nurse teaches an older adult with a decreased production of estrogen. Which statement should the nurse include in this clients teaching to decrease injury?
- A. Drink at least 2 liters of fluids each day.
- B. Walk daily as a weight-bearing exercise.
- C. Bathe your perineal area twice a day.
- D. You should check your blood glucose before meals.
Correct Answer: B
Rationale: Decreased estrogen in older adults increases the risk of osteoporosis and fractures. Weight-bearing exercises like walking help maintain bone density and reduce injury risk.
A nurse prepares to palpate a clients thyroid gland. Which action should the nurse take when performing this assessment?
- A. Stand in front of the client instead of behind the client.
- B. Ask the client to swallow after palpating the thyroid.
- C. Palpate the right lobe with the nurses left hand.
- D. Place the client in a sitting position with the chin tucked down.
Correct Answer: D
Rationale: The correct technique for thyroid palpation involves the nurse standing behind the client, with the client in a sitting position and chin tucked down to relax the neck muscles, facilitating palpation of the thyroid gland.
A nurse cares for a client with a deficiency of aldosterone. Which assessment finding should the nurse correlates with this deficiency?
- A. Increased urine output
- B. Vasoconstriction
- C. Blood glucose of 90 mg/L
- D. Normal sodium levels
Correct Answer: A
Rationale: Aldosterone, the major mineralocorticoid, maintains extracellular fluid volume. It promotes sodium and water reabsorption and potassium excretion in the kidney tubules. A client with an aldosterone deficiency will have increased urine output due to decreased reabsorption of sodium and water.
A nurse cares for a client with a hypofunctioning anterior pituitary gland. Which hormones should the nurse expect to be affected by this condition? (Select all that apply.)
- A. Thyroid-stimulating hormone
- B. Vasopressin
- C. Follicle-stimulating hormone
- D. Calcitonin
- E. Growth hormone
Correct Answer: A,C,E
Rationale: The anterior pituitary gland secretes thyroid-stimulating hormone, follicle-stimulating hormone, and growth hormone, which would be affected by hypofunction. Vasopressin and calcitonin are secreted by the posterior pituitary and thyroid gland, respectively.