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A nurse collecting data from a client who has dehydration. Which of the following findings should the nurse expect?
- A. High blood pressure
- B. Moist skin
- C. Dark-colored urine
- D. Distended neck veins
Correct Answer: C
Rationale: Dark urine indicates dehydration as kidneys concentrate urine to conserve water.
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A nurse is collecting data on a client who has impaired mobility. The nurse should monitor the client for a pressure injury due to which of the following factors?
- A. Increased collagen
- B. Increased muscle mass
- C. Decreased serum calcium
- D. Decreased circulation
Correct Answer: D
Rationale: Decreased circulation from immobility reduces tissue oxygenation, increasing pressure injury risk.
A nurse is collecting data from a client who has an inadequate dietary intake of fiber. Which of the following findings should the nurse expect?
- A. Constipation
- B. Memory loss
- C. Brittle hair
- D. Bleeding gums
Correct Answer: A
Rationale: Insufficient fiber causes constipation by reducing bowel movement frequency.
A nurse is reinforcing teaching about how to use an incentive spirometer with a client. Which of the following statements should the nurse make?
- A. Hold your breath for 7 seconds when using the incentive spirometer.
- B. Sit up at a 30-degree angle when using the incentive spirometer.
- C. Use the incentive spirometer once every 4 hours.
- D. Inhale through the incentive spirometer 10 times with each use.
Correct Answer: A
Rationale: Holding breath for up to 7 seconds maximizes lung expansion, a key goal of incentive spirometry.
A nurse is collecting data on a client who is experiencing hypovolemia. Which of the following findings should the nurse expect?
- A. Peripheral edema
- B. Oliguria
- C. Hypertension
- D. Bradycardia
Correct Answer: B
Rationale: Oliguria occurs in hypovolemia as kidneys conserve fluid due to low volume.
A nurse administers subcutaneous NPH insulin at 0700 to a child who has diabetes. At which of the following times should the nurse observe for hypoglycemia caused by the onset of the medication?
- A. 715
- B. 730
- C. 1200
- D. 900
Correct Answer: D
Rationale: NPH insulin onset is 1-2 hours; 0900 (2 hours post-0700) is when hypoglycemia may begin.