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A nurse is assessing a client who has had diarrhea for several days. Which of the following findings should the nurse expect?
- A. Dehydration
- B. Rigid abdomen
- C. Hypothermia
- D. Decreased bowel sounds
Correct Answer: A
Rationale: The correct answer is A: Dehydration. Diarrhea can lead to fluid and electrolyte loss, resulting in dehydration. Symptoms may include increased thirst, dry mouth, decreased urine output, and sunken eyes. Dehydration can be dangerous if not addressed promptly. Choices B, C, and D are unlikely findings with diarrhea. A rigid abdomen suggests a more serious condition like peritonitis, hypothermia is not a typical complication of diarrhea, and decreased bowel sounds may indicate a paralytic ileus, not commonly associated with diarrhea.
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A nurse is assessing a client who has circulatory overload. Which of the following findings should the nurse expect?
- A. Diaphoresis
- B. Weight loss
- C. Hypotension
- D. Tachycardia
Correct Answer: D
Rationale: The correct answer is D: Tachycardia. In circulatory overload, the body is trying to compensate for the increased volume of fluid in the circulatory system by increasing the heart rate to maintain adequate circulation. Diaphoresis (A) is excessive sweating, not typically associated with circulatory overload. Weight loss (B) is not expected as circulatory overload is characterized by excess fluid retention. Hypotension (C) is unlikely as the body's response to fluid overload is to increase blood pressure. Tachycardia (D) is the correct choice as the heart rate increases to help pump the excess fluid throughout the body.
A nurse is receiving a telephone prescription for a client from a provider. Which of the following actions should the nurse take when transcribing the prescription?
- A. Use the provider’s initials after the prescription
- B. Repeat the prescription to the provider
- C. Write the prescription in shorthand
- D. Read back the prescription to the provider
Correct Answer: D
Rationale: The correct answer is D: Read back the prescription to the provider. This is crucial to ensure accuracy and prevent errors. By reading back the prescription, the nurse confirms understanding and allows the provider to clarify any misunderstandings immediately. This step promotes patient safety and effective communication.
Choice A (Use the provider’s initials after the prescription) is incorrect because it does not address the need for verification of the prescription details. Choice B (Repeat the prescription to the provider) is not as effective as reading back, as it may not ensure complete accuracy. Choice C (Write the prescription in shorthand) can lead to misinterpretation and errors.
A charge nurse is reviewing the documentation completed by a newly licensed nurse. Which of the following entries should the charge nurse recommend for revision?
- A. The client demonstrated proper technique when drawing up 8 units of insulin
- B. The client stated ‘I struggle to see those little lines on the syringe’
- C. The client FBS was 95 mg/dL
- D. The client seems to be more comfortable performing self-administration of insulin
Correct Answer: D
Rationale: The correct answer is D. The charge nurse should recommend revising this entry because it implies the client is self-administering insulin, which is beyond the scope of practice for a client. This could lead to serious harm if not addressed.
A, B, and C are incorrect because they all indicate proper client care and documentation. A shows proper technique, B indicates client's concern with syringe lines, and C provides the client's fasting blood sugar level.
A nurse is caring for a client who is on bedrest and is experiencing constipation. Which of the following interventions should the nurse implement?
- A. Place the client on a low-fiber diet
- B. Request a prescription for a mineral oil for the client
- C. Encourage the client to drink cold fluids
- D. Increase the client's fluid intake
Correct Answer: D
Rationale: The correct answer is D: Increase the client's fluid intake. This intervention helps prevent constipation by promoting hydration and softening stool. Adequate fluid intake aids in maintaining bowel motility and preventing hard stools. Low-fiber diet (A) can exacerbate constipation. Mineral oil (B) can lead to complications and should be avoided. Cold fluids (C) may cause discomfort and are not directly related to improving constipation. In summary, increasing fluid intake is the most appropriate intervention to address constipation in a client on bedrest.
A nurse is preparing to administer furosemide 30 mg IV bolus stat. Available is furosemide injection 10 mg/mL. How many mL should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer: 3
Rationale: To determine the correct mL of furosemide to administer, we can use the formula: Desired dose (30 mg) / Available dose (10 mg/mL) = mL to administer. So, 30 mg / 10 mg/mL = 3 mL. The correct answer is therefore 3 mL.
Choice A: Incorrect. This answer does not provide the correct calculation based on the given information.
Choice B: Incorrect. This answer does not demonstrate the correct calculation based on the given information.
Choice C: Incorrect. This answer does not reflect the accurate calculation using the provided data.
Choice D: Incorrect. This choice does not show the correct calculation based on the information presented.
Choice E: Incorrect. This response does not align with the correct calculation method for determining the mL to administer.
Choice F: Incorrect. This choice does not offer the accurate calculation based on the provided data.
Choice G: Incorrect. This answer does not demonstrate the correct calculation using the