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A nurse is assessing a client for fluid volume deficit following lumbar spinal surgery. The nurse should identify which of the following findings as an indication the client is at risk for fluid volume deficit?
- A. Surgical drain output 300 mL during an 8-hr shift
- B. Bounding peripheral pulses
- C. Neck vein distention
- D. Weight gain of 2 kg (4.4 lb) in 24 hours
Correct Answer: A
Rationale: The correct answer is A: Surgical drain output 300 mL during an 8-hr shift. This finding indicates potential fluid loss, which can lead to fluid volume deficit. Surgical drain output is a direct measure of fluid loss from the body and can help assess the client's fluid status. Bounding peripheral pulses (B) and neck vein distention (C) are signs of fluid volume excess, not deficit. Weight gain of 2 kg (4.4 lb) in 24 hours (D) suggests fluid retention, not deficit.
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A nurse is caring for a group of clients. In which of the following scenarios is the nurse acting as a client advocate?
- A. Encouraging a client to take pain medication despite refusal.
- B. Referring a client who has COPD for palliative care services.
- C. Discharging a client early to free up hospital beds.
- D. Withholding information about a new diagnosis to prevent distress.
Correct Answer: B
Rationale: The correct answer is B because referring a client with COPD for palliative care services demonstrates advocating for the client's best interest, ensuring they receive appropriate care to manage symptoms and improve quality of life. This action aligns with the nurse's role as a client advocate by advocating for the client's autonomy and well-being. In contrast, choices A, C, and D do not prioritize the client's best interests or rights. Choice A disregards the client's autonomy by encouraging medication against their wishes. Choice C prioritizes hospital efficiency over the client's needs. Choice D violates the client's right to informed decision-making by withholding essential information. Overall, choice B best exemplifies client advocacy in nursing practice.
A home health nurse is assisting a client with planning care for a family member who has Alzheimers disease. Which of the following instructions should the nurse include?
- A. Review the daily schedule with the client every morning.
- B. Limit the clients fluid intake to prevent accidents.
- C. Encourage the client to engage in complex tasks.
- D. Restrict the clients social interactions to reduce confusion.
Correct Answer: A
Rationale: The correct answer is A: Review the daily schedule with the client every morning. This instruction is important for individuals with Alzheimer's disease as it helps provide structure and routine, which can help reduce confusion and anxiety. By reviewing the daily schedule, the client can be prepared for the day's activities, promoting a sense of familiarity and independence.
Option B is incorrect because limiting fluid intake can lead to dehydration and other health issues. Option C is incorrect as individuals with Alzheimer's disease may struggle with complex tasks and may become frustrated. Option D is incorrect because social interactions are important for mental stimulation and emotional well-being, restricting them can lead to increased confusion and isolation.
A nurse is assessing a client who has a new diagnosis of pericarditis. Which of the following findings should the nurse identify as a manifestation of cardiac tamponade?
- A. Atrial fibrillation
- B. Jugular vein distention
- C. Bradycardia
- D. Hypotension
Correct Answer: B
Rationale: The correct answer is B: Jugular vein distention. In cardiac tamponade, fluid accumulates in the pericardial sac, compressing the heart. This leads to increased pressure in the heart chambers, causing jugular vein distention due to impaired venous return. A: Atrial fibrillation is a common arrhythmia but not specific to cardiac tamponade. C: Bradycardia is not a typical finding in cardiac tamponade as the body tries to compensate for decreased cardiac output. D: Hypotension can be present but is a late sign and not specific to cardiac tamponade.
A nurse is inspecting the skin of a client who has basal cell carcinoma. The nurse should identify which of the following lesion characteristics on the clients skin?
- A. A pearly, waxy nodule
- B. A scaly, red patch
- C. A dark, irregular mole
- D. A firm, painless lump
Correct Answer: A
Rationale: The correct answer is A: A pearly, waxy nodule. Basal cell carcinoma typically presents as a pearly, waxy nodule on the skin. This characteristic appearance is due to the growth of abnormal cells in the basal cell layer of the skin. The nodule may also have small blood vessels visible on its surface. This presentation is distinct from other skin lesions. Choice B, a scaly red patch, is more indicative of conditions like psoriasis or eczema. Choice C, a dark irregular mole, is more suggestive of melanoma. Choice D, a firm, painless lump, is more characteristic of conditions like lipomas or fibromas. Thus, the correct answer is A based on the specific characteristics of basal cell carcinoma.
A nurse is providing discharge teaching about infection control at home for a client who has tuberculosis. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will place my used tissues in a plastic bag.
- B. I will share my utensils with my family.
- C. I will not need to wear a mask at home.
- D. I will stop taking my medications when I feel better.
Correct Answer: A
Rationale: The correct answer is A: "I will place my used tissues in a plastic bag." This statement indicates understanding of infection control for tuberculosis by properly disposing of contaminated materials to prevent the spread of the disease. Placing used tissues in a plastic bag helps contain the bacteria.
Choices B, C, and D are incorrect:
B: Sharing utensils can spread the infection to family members.
C: Not wearing a mask at home can expose others to the bacteria.
D: Stopping medications prematurely can lead to treatment failure and drug resistance.