Nokea
A nurse is administering furosemide IV bolus to a client who has fluid volume excess. The nurse should recognize which of the following findings as an indication that the medication has been effective?
- A. Increased blood pressure
- B. Weight Loss
- C. Decreased inflammation
- D. Decreased pain
Correct Answer: B
Rationale: The correct answer is B: Weight Loss. Furosemide is a loop diuretic that helps the body excrete excess fluid and sodium through increased urine output. Therefore, weight loss would indicate that the medication has been effective in reducing the client's fluid volume excess. Increased blood pressure (A) would not be an expected finding as furosemide typically helps lower blood pressure. Decreased inflammation (C) and decreased pain (D) are not directly related to the action of furosemide as a diuretic.
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A nurse is caring for a client whose partner recently died. The nurse sits with the client to provide comfort. Which of the following ethical principles is the nurse demonstrating?
- A. Fidelity
- B. Veracity
- C. Autonomy
- D. Beneficence
Correct Answer: D
Rationale: The correct answer is D: Beneficence. Beneficence is the ethical principle that involves doing good and promoting the well-being of others. By sitting with the client to provide comfort after the loss of their partner, the nurse is demonstrating beneficence by showing compassion and support. Fidelity (A) relates to keeping promises and being faithful to commitments. Veracity (B) is about truthfulness and honesty. Autonomy (C) refers to respecting the client's right to make their own decisions. The other choices are not directly related to the nurse's action of providing comfort in this context.
Which of the following actions should the nurse plan to take?
- A. Launch a media campaign to increase awareness about industrial pollution
- B. Have a nurse from outside the community provide health lectures at the county hospital
- C. Encourage rural residents to focus health spending on tertiary health interventions
- D. Provide anticipatory guidance classes to parents through public schools
Correct Answer: D
Rationale: The correct answer is D because providing anticipatory guidance classes to parents through public schools is a proactive approach to promote health and prevent illness in the community. This action empowers parents with knowledge and skills to make informed health decisions for their children. Launching a media campaign (A) may raise awareness but may not directly impact individual behavior change. Having a nurse from outside the community provide health lectures (B) may not be as effective as someone familiar with the community's specific needs. Encouraging rural residents to focus on tertiary health interventions (C) is reactive and may not address prevention.
Which of the following statements by the client indicates an understanding of the teaching?
- A. I should keep the medication in the original container.
- B. I should replace any unused medication every 6 months.
- C. I can store the medication in the refrigerator.
- D. I can crush the medication and mix with applesauce.
Correct Answer: A
Rationale: The correct answer is A because keeping medication in the original container ensures proper identification, dosage, and expiration monitoring. Choice B is incorrect as replacing unused medication every 6 months may lead to waste. Choice C is incorrect as not all medications should be stored in the refrigerator. Choice D is incorrect as crushing medication may alter its effectiveness or cause harm. It is important for the client to understand the importance of following specific storage instructions provided with the medication, making choice A the most appropriate response.
A nurse is providing discharge teaching to a client who is postoperative following the surgical repair of a detached retina. Which of the following statements by the client indicates an understanding of the teaching?
- A. I can go jogging after 2 weeks.â€
- B. I should bend at the waist when putting on my shoes.â€
- C. I can lift objects that are less than 10 pounds.
- D. I can resume activities: such sewing.â€
Correct Answer: D
Rationale: The correct answer is D: "I can resume activities such as sewing." This indicates an understanding of the teaching because it shows the client recognizes the need to avoid strenuous activities that may increase intraocular pressure, thus risking damage to the repaired retina. Sewing is a low-impact activity that does not involve heavy lifting or sudden movements, making it safe for the client postoperatively.
Choice A is incorrect because jogging is a high-impact activity that should be avoided for several weeks post-surgery. Choice B is incorrect because bending at the waist can increase intraocular pressure, which is not recommended post-detached retina repair. Choice C is incorrect as lifting objects, even if less than 10 pounds, can also increase intraocular pressure.
Which of the following statements should the nurse include in the hand-off report?
- A. The estimated blood loss was 250 milliliters.
- B. The client is a member of the board of directors.
- C. There was a total of 10 sponges used during the procedure.
- D. The client was intubated without complications.
Correct Answer: A
Rationale: The correct answer is A: The estimated blood loss was 250 milliliters. This statement is crucial in a hand-off report as it provides important information about the client's condition post-procedure. It helps alert the receiving nurse to any potential complications or the need for further monitoring.
Statement B is incorrect as the client's position on the board of directors is not relevant to the client's immediate care needs and does not provide useful clinical information. Statement C, the number of sponges used, is also irrelevant to the client's immediate condition and does not impact the client's ongoing care.
Statement D, mentioning intubation without complications, could be important in certain contexts, but in this scenario, information about blood loss is more critical for the receiving nurse to be aware of.