Nokea
A nurse is assessing a client who has chronic kidney disease for fluid volume increase. Which of the following provides a reliable measure of fluid retention?
- A. Sodium level
- B. Intake and output
- C. Daily weight
- D. Tissue turgor
Correct Answer: C
Rationale: Daily weight is the most reliable measure of fluid retention as 1 kg weight gain equals approximately 1 liter fluid retention.
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The nurse is reviewing laboratory test results for the client with liver disease and notes that the client's albumin level is low. Which nursing assessment indicates low albumin levels?
- A. Evaluate for asterixis
- B. Palpate for peripheral edema
- C. Evaluate for decreased level of consciousness
- D. Inspect for petechiae
Correct Answer: B
Rationale: Peripheral edema occurs with hypoalbuminemia due to decreased oncotic pressure causing fluid leakage into tissues.
A nurse is caring for a client who develops a pulmonary embolism. Which of the following interventions should the nurse implement first?
- A. Administer oxygen therapy
- B. Start an IV infusion of Lactated Ringer's
- C. Initiate cardiac monitoring
- D. Give morphine IV
Correct Answer: A
Rationale: Oxygen is first priority to address hypoxemia caused by PE.
A nurse is assessing a client and discovers the infusion pump with the client's total parenteral nutrition (TPN) solution is not infusing. The nurse should monitor the client for which of the following clinical manifestations?
- A. Fever and chills
- B. Hypertension and crackles
- C. Excessive thirst and urination
- D. Shakiness and diaphoresis
Correct Answer: D
Rationale: These are signs of hypoglycemia from sudden TPN interruption.
A nurse is reviewing the BUN and creatinine levels of an older adult client who has chronic kidney disease (CKD). Which of the following findings should the nurse expect?
- A. BUN 8 mg/dL and creatinine 0.7 mg/dL
- B. BUN 45 mg/dL and creatinine 8 mg/dL
- C. BUN 10 mg/dL and creatinine 0.3 mg/dL
- D. BUN 23 mg/dL and creatinine 1.0 mg/dL
Correct Answer: B
Rationale: Elevated BUN and creatinine reflect impaired kidney function in CKD.
A nurse in the emergency department is caring for a client who had a seizure and became unresponsive after stating they had a sudden, severe headache. The client's vital signs are as follows: blood pressure of 198/110 mm Hg, pulse of 82/min, respirations of 24/min, and a temperature of 38.2° C (100.8° F). Which of the following neurological disorders should the nurse suspect?
- A. Embolic stroke
- B. Thrombotic stroke
- C. Transient ischemic attack (TIA)
- D. Hemorrhagic stroke
Correct Answer: D
Rationale: The sudden severe headache followed by seizure and unresponsiveness with elevated BP suggests hemorrhagic stroke.