Nokea
A nurse is assessing a client who has fluid overload. Which of the following findings should the nurse expect? (Select all that apply.)
- A. Increased blood pressure
- B. Increased hematocrit
- C. Increased respiratory rate
- D. Increased heart rate
- E. Increased temperature
Correct Answer: A,C,D
Rationale: The correct answer is A, C, and D. Fluid overload leads to increased blood pressure due to the increased volume of fluid in the vascular system. Increased respiratory rate occurs as the body tries to compensate for the excess fluid by increasing oxygen intake. Increased heart rate is a response to the increased workload on the heart to pump the excess fluid. Increased hematocrit and temperature are not typically associated with fluid overload. Hematocrit may actually be decreased due to hemodilution, and temperature is usually unaffected unless there is an underlying infection.
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A nurse is caring for four clients who have drainage tubes. Which of the following clients should the nurse recognize as being at risk for hypokalemia?
- A. The client who has a nasogastric (NG) tube to suction
- B. The client who has a chest tube to water seal
- C. The client who has an indwelling urinary catheter to gravity drainage
- D. The client who has a tracheostomy tube attached to humidified oxygen
Correct Answer: A
Rationale: The correct answer is A: The client who has a nasogastric (NG) tube to suction. Suctioning through the NG tube can lead to loss of gastric contents, including potassium, which can result in hypokalemia. The other choices do not directly affect potassium levels. B: A chest tube to water seal is used to drain air or fluid from the pleural space, not likely to cause hypokalemia. C: An indwelling urinary catheter to gravity drainage does not impact potassium levels. D: A tracheostomy tube with humidified oxygen does not affect potassium levels. Therefore, the client with the NG tube to suction is at risk for hypokalemia due to potential potassium loss.
A nurse is teaching a newly licensed nurse about preventing puncture injuries. Which of the following instructions should the nurse include?
- A. Break needles on syringes before disposal
- B. Use two hands to recap a needle after administering a medication
- C. Dispose of used razors in wastebaskets
- D. Replace sharps containers when they are 3/4 full
Correct Answer: D
Rationale: The correct answer is D: Replace sharps containers when they are 3/4 full. This instruction is crucial in preventing puncture injuries as overfilling sharps containers can increase the risk of accidental needle sticks. By replacing the containers when they are 3/4 full, it ensures that there is enough space to safely dispose of needles and other sharp objects without risking spills or injuries.
Explanation of other choices:
A: Breaking needles on syringes before disposal is unsafe as it can increase the risk of needle stick injuries.
B: Using two hands to recap a needle is dangerous and not recommended as it can lead to accidental needle sticks.
C: Disposing of used razors in wastebaskets is improper as they should be disposed of in puncture-proof containers.
Summary: Option D is the correct choice as it emphasizes safe disposal practices to prevent puncture injuries, while the other options promote unsafe practices that can increase the risk of needle stick injuries.
A nurse is reviewing a fall risk assessment for a client. Which of the following findings places the client at risk for a fall? Select all that apply.
- A. Electrical cord on floor over a walkway
- B. Demonstrates correct use of cane to ambulate
- C. Grab bar in the bathroom
- D. Diagnosis of macular degeneration
- E. Throw rugs in kitchen
Correct Answer: A,D,E
Rationale: Correct Answer: A, D, E
Rationale:
- A: An electrical cord on the floor is a tripping hazard, increasing the risk of falls.
- D: Macular degeneration affects vision, leading to difficulties in depth perception and obstacle detection, increasing fall risk.
- E: Throw rugs in the kitchen can cause slipping or tripping, posing a fall hazard.
Summary of Incorrect Choices:
- B: Demonstrating correct use of a cane indicates the client is taking precautions to prevent falls.
- C: Having a grab bar in the bathroom is a safety measure to prevent falls.
- F and G: Not provided in the question, so cannot be evaluated.
A nurse is preparing to administer clonazepam 5 mg PO in 3 equally divided doses every 8 hr for a client who has seizures. The amount available is clonazepam 0.5 mg tablets. How many tablets should the nurse administer per dose? (Round off to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer: 1
Rationale: Correct Answer: 1
Rationale: To calculate the number of tablets per dose, divide the total dose (5 mg) by the dose per tablet (0.5 mg).
5 mg / 0.5 mg = 10 tablets for the total dose.
Since the total dose is divided into 3 equal doses, divide the total tablets by 3.
10 tablets / 3 = 3.33 tablets per dose.
Round off to the nearest tenth, which is 3.3.
Since we cannot administer a partial tablet, the nurse should administer 1 tablet per dose.
Summary:
A: 1 - Correct. Calculated based on dividing total dose by dose per tablet and rounding off.
B: 2 - Incorrect. Not the correct calculation based on the dose per tablet.
C: 3 - Incorrect. Not the correct calculation based on the dose per tablet.
D: 4 - Incorrect. Not the correct calculation based on the dose per tablet.
E
A nurse is teaching a client about the Rinne test. Which of the following client statements indicates an understanding of the teaching?
- A. I will wear earphones during this test
- B. A small probe is placed inside my ear
- C. A tuning fork is placed on my head
- D. Small electrodes are placed on my scalp
Correct Answer: C
Rationale: The correct answer is C: A tuning fork is placed on my head. In the Rinne test, a tuning fork is first placed against the client's mastoid bone behind the ear and then moved near the ear canal. The client should hear the sound louder when the fork is near the ear if the test is normal. Choice A is incorrect because earphones are not used in the Rinne test. Choice B is incorrect as a probe is not inserted into the ear. Choice D is incorrect as electrodes are not part of the Rinne test. Placing a tuning fork on the head is the correct step in performing the Rinne test to assess hearing conduction.