Nokea
A nurse is assessing a client who has syndrome of inappropriate antidiuretic hormone (SIADH). Which of the following findings should the nurse expect?
- A. Increased urine output
- B. Increased serum sodium
- C. Hyponatremia
- D. Hypercalcemia
Correct Answer: C
Rationale: In clients with Syndrome of Inappropriate Antidiuretic Hormone (SIADH), the nurse should expect hyponatremia. SIADH leads to excess water retention, diluting the sodium levels in the blood, resulting in low serum sodium levels. Choice A, increased urine output, is incorrect as SIADH causes water retention, leading to decreased urine output. Choice B, increased serum sodium, is incorrect because SIADH causes a dilutional effect due to water retention, resulting in decreased serum sodium levels. Choice D, hypercalcemia, is unrelated to SIADH and not a typical finding.
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What is the initial step in managing a suspected pulmonary embolism in a patient?
- A. Administer oxygen
- B. Reposition the patient
- C. Administer anticoagulants
- D. Administer IV fluids
Correct Answer: A
Rationale: Administering oxygen is the initial step in managing a suspected pulmonary embolism. Oxygen therapy is crucial to improve oxygenation levels in the blood when there is a suspected blockage in the pulmonary artery. Administering anticoagulants, although important in the treatment of pulmonary embolism, is not the first step as ensuring adequate oxygen supply takes precedence. Repositioning the patient or administering IV fluids are not the primary interventions for a suspected pulmonary embolism and are not as essential as providing oxygen support.
A nurse is planning care for a client who had gastric bypass surgery 1 week ago and has signs of early dumping syndrome. Which of the following findings should the nurse expect?
- A. Facial flushing
- B. Syncope
- C. Diaphoresis
- D. Bradycardia
Correct Answer: A
Rationale: Facial flushing is a common symptom of early dumping syndrome, which occurs when food moves too quickly into the small intestine. This rapid movement triggers the release of vasoactive peptides causing vasodilation, leading to facial flushing. Syncope (choice B) is not a typical finding in early dumping syndrome. Diaphoresis (choice C) and bradycardia (choice D) are also not characteristic symptoms of early dumping syndrome.
What is the priority intervention for a patient with suspected pulmonary embolism?
- A. Administer oxygen
- B. Administer anticoagulants
- C. Administer bronchodilators
- D. Reposition the patient
Correct Answer: A
Rationale: Administering oxygen is the priority intervention for a patient with suspected pulmonary embolism. Maintaining adequate oxygenation is crucial in these patients to prevent hypoxemia and support oxygen delivery to tissues. Administering anticoagulants may be necessary but is not the initial priority. Administering bronchodilators is not indicated for pulmonary embolism. Repositioning the patient does not address the immediate need for oxygenation.
A nurse is caring for a client who is 1 day postoperative following a transurethral resection of the prostate (TURP). Which of the following findings should the nurse report to the provider?
- A. Urine output of 30 mL/hr
- B. Pink-tinged urine
- C. Small blood clots in the urine
- D. Blood pressure of 114/78 mm Hg
Correct Answer: C
Rationale: The presence of small blood clots in the urine is an expected finding after a TURP due to the surgical manipulation of the prostate bed and the bladder. However, larger clots can indicate excessive bleeding and should be reported promptly. Urine output of 30 mL/hr is within the expected range for post-TURP clients, indicating adequate kidney perfusion. Pink-tinged urine is also normal after a TURP due to minor bleeding from the surgical site. A blood pressure of 114/78 mm Hg is within normal limits and does not require immediate reporting.
What is the best method to assess for fluid overload in patients with heart failure?
- A. Monitor daily weight
- B. Check for jugular vein distention
- C. Check for pitting edema
- D. Check for fluid retention
Correct Answer: A
Rationale: The correct answer is A: Monitor daily weight. Daily weight monitoring is the most accurate method to assess fluid overload in patients with heart failure. Changes in weight can indicate fluid retention before visible signs like jugular vein distention or pitting edema appear. Checking for jugular vein distention (choice B) is helpful but may not be as sensitive as daily weight monitoring. Pitting edema (choice C) and fluid retention (choice D) are signs of fluid overload, but daily weight monitoring is a more proactive approach to detect changes early.