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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A nurse is preparing to administer a 2 mg IV bolus of morphine sulfate. Morphine sulfate is available in a concentration of 10 mg/mL. How many mL should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer: 0.2
Rationale: Calculation: 2 mg ÷ 10 mg/mL = 0.2 mL
A nurse is preparing to instill 840 mL of enteral nutrition via a client's gastrostomy tube over a 24-hour period using an infusion pump. The nurse should set the infusion pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer: 35
Rationale: Calculation: 840 mL ÷ 24 hours = 35 mL/hr
A nurse is assessing a client who has left-sided heart failure. Which of the following clinical manifestations will the nurse expect?
- A. Lower extremity edema
- B. Crackles in lung bases
- C. Jugular vein distention
- D. Ascites
Correct Answer: B
Rationale: Crackles indicate pulmonary congestion characteristic of left-sided heart failure.
The nurse is caring for a client with advanced cirrhosis. Which of the following clinical manifestations should the nurse recognize as a serious complication of this condition?
- A. Frequent nosebleeds and bruising
- B. Urinary retention
- C. No bowel movement in three days
- D. Increased blood glucose
Correct Answer: A
Rationale: Coagulopathy (evidenced by bleeding) is serious in cirrhosis due to impaired clotting factor production.
A nurse is assessing a client who has sustained a traumatic brain injury. The nurse should monitor the client for which of the following manifestations of increased intracranial pressure?
- A. Tachypnea
- B. Hypotension
- C. Decreased level of consciousness
- D. Bilateral weakness of extremities
Correct Answer: C
Rationale: Decreased LOC is the earliest and most sensitive sign of increased ICP.