Nokea
A nurse is assessing a client who is postoperative following a bowel resection. Which of the following findings should the nurse report to the provider?
- A. Heart rate 110/min.
- B. Temperature of 37.4°C (99.3°F).
- C. Respiratory rate of 18/min.
- D. Urine output of 20 mL/hr.
Correct Answer: D
Rationale: A urine output of 20 mL/hr is below the expected range and indicates potential renal failure, requiring immediate intervention. In postoperative patients, a urine output less than 30 mL/hr suggests inadequate renal perfusion, a concern that needs prompt attention to prevent renal complications. The heart rate of 110/min, temperature of 37.4°C (99.3°F), and respiratory rate of 18/min are within normal ranges for a postoperative client and do not indicate immediate issues.
You may also like to solve these questions
A parent is being taught by a nurse how to prevent sudden infant death syndrome (SIDS). Which statement by the parent indicates an understanding of how to place the infant in the crib at bedtime?
- A. Place the infant on their stomach to sleep.
- B. Place the infant on their side to sleep.
- C. Place the infant on their back to sleep.
- D. Allow the infant to sleep with a pacifier.
Correct Answer: C
Rationale: The correct answer is C: 'Place the infant on their back to sleep.' This statement indicates an understanding of the recommended sleep position to reduce the risk of SIDS. Placing infants on their back is the safest sleep position according to guidelines to prevent SIDS. Choices A and B are incorrect as placing the infant on their stomach or side increases the risk of SIDS. While allowing the infant to sleep with a pacifier can also reduce the risk of SIDS, the most crucial step is placing the infant on their back for sleep.
A nurse is preparing to administer a unit of packed RBCs to a client. Which of the following actions should the nurse take first?
- A. Check the client's identification band
- B. Verify the provider's prescription
- C. Prime the IV tubing with 0.9% sodium chloride
- D. Obtain the client's vital signs
Correct Answer: A
Rationale: The correct first action for the nurse to take when preparing to administer a unit of packed RBCs is to check the client's identification band. This step is crucial to ensure that the correct blood is administered to the right client, preventing any errors or adverse reactions. Verifying the provider's prescription, priming the IV tubing, and obtaining the client's vital signs are important steps in the process but should follow the initial identification check to prioritize patient safety.
A nurse is providing dietary teaching to a client who has chronic kidney disease. Which of the following foods should the nurse instruct the client to avoid?
- A. Apples.
- B. White bread.
- C. Bananas.
- D. Grapes.
Correct Answer: C
Rationale: Bananas are high in potassium, which should be avoided by clients with chronic kidney disease to prevent hyperkalemia. Apples, white bread, and grapes do not have high potassium levels and are generally acceptable for clients with chronic kidney disease unless they have other specific dietary restrictions.
A nurse is preparing to administer a rectal suppository to a client. What action should the nurse take?
- A. Encourage the client to hold their breath as long as possible.
- B. Insert the suppository just past the anal sphincter.
- C. Lubricate the suppository and insert it 1.5 cm (0.6 in) into the rectum.
- D. Place the client in a Sims' position before inserting the suppository.
Correct Answer: D
Rationale: The correct action the nurse should take when administering a rectal suppository is to place the client in a Sims' position. This position helps facilitate the proper administration of the suppository by allowing better access to the rectum. Encouraging the client to hold their breath as long as possible (Choice A) is unnecessary and not related to the administration of a rectal suppository. Inserting the suppository just past the anal sphincter (Choice B) is incorrect as it may not reach the rectum where it needs to be placed. Lubricating the suppository and inserting it 1.5 cm into the rectum (Choice C) is incorrect as the suppository needs to be inserted deeper into the rectum for proper absorption.
A nurse is caring for a client who has heart failure and a prescription for furosemide. Which of the following findings should the nurse identify as an indication that the medication is effective?
- A. Increased shortness of breath.
- B. Decreased peripheral edema.
- C. Increased jugular venous distention.
- D. Increased heart rate.
Correct Answer: B
Rationale: The correct answer is B: Decreased peripheral edema. Furosemide is a diuretic that helps in reducing fluid overload in clients with heart failure by increasing urine output. A decrease in peripheral edema indicates that the medication is effectively removing excess fluid from the body. Choices A, C, and D are incorrect because they do not indicate an improvement in the client's condition. Increased shortness of breath, increased jugular venous distention, and increased heart rate are all signs of worsening heart failure and would not be expected findings when furosemide is effective.