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A nurse is assessing a client who reports frequent vomiting and diarrhea for the past 3 days. Which of the following findings should the nurse expect? (Select all that apply)
- A. Fat neck veins.
- B. Hypotension.
- C. Poor skin turgor.
- D. Bradycardia.
- E. Pale yellow urine.
Correct Answer: B,C
Rationale: The correct answers are B: Hypotension and C: Poor skin turgor. In a client with frequent vomiting and diarrhea, fluid loss leads to dehydration, causing hypotension and poor skin turgor. Hypotension results from decreased circulating blood volume due to fluid loss. Poor skin turgor occurs due to decreased skin elasticity from dehydration. Choices A, D, and E are incorrect. Fat neck veins are not typical findings in dehydration. Bradycardia is not expected in dehydration; tachycardia is more common due to compensatory mechanisms to maintain cardiac output. Pale yellow urine is indicative of concentrated urine, not a typical finding in dehydration.
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A nurse is assessing a client who is in skeletal traction. Which of the following findings should the nurse identify as an indication of infection at the pin sites?
- A. Serosanguineous drainage.
- B. Mild erythema.
- C. Warmth.
- D. Fever.
Correct Answer: D
Rationale: The correct answer is D: Fever. Infection at the pin sites in skeletal traction can lead to systemic signs such as fever. Fever is a common indicator of infection as the body responds to pathogens by increasing its temperature. Serosanguineous drainage, mild erythema, and warmth can be normal findings in the early stages of healing or due to inflammation, but fever indicates a more serious underlying issue like infection. Therefore, the nurse should prioritize monitoring for fever to promptly identify and address any potential infection.
A nurse is teaching a class about preventive care to clients who are at risk for acquiring viral hepatitis. Which of the following information should the nurse include in the presentation?
- A. Avoid handwashing after eating.
- B. Avoid foods prepared with tap water.
- C. Avoid eating meat.
- D. Avoid covering sores with bandages.
Correct Answer: B
Rationale: The correct answer is B: Avoid foods prepared with tap water. This is important because tap water in certain regions may be contaminated with hepatitis-causing viruses. Avoiding tap water in food preparation reduces the risk of contracting viral hepatitis. Handwashing after eating (A) is actually recommended for preventing the spread of infections. Avoiding eating meat (C) is not necessary for preventing viral hepatitis transmission. Covering sores with bandages (D) is unrelated to the prevention of viral hepatitis.
A client seeks medical attention for intermittent signs and symptoms that suggest a diagnosis of Raynaud’s disease. The nurse should assess the trigger of these signs/symptoms by asking which?
- A. Does drinking coffee or ingesting chocolate seem related to the episodes?
- B. Does being exposed to heat seem to cause the episodes?
- C. Do the signs and symptoms occur while you are asleep?
- D. Have you experienced any injuries that have limited your activity levels lately?
Correct Answer: A
Rationale: The correct answer is A: Does drinking coffee or ingesting chocolate seem related to the episodes? This question is relevant because caffeine and chocolate are known triggers for Raynaud's disease due to their vasoconstrictive properties. By asking about these specific triggers, the nurse can gather important information to help identify potential causes of the client's symptoms.
Choice B is incorrect because exposure to heat typically alleviates symptoms of Raynaud's disease rather than causing them. Choice C is irrelevant as Raynaud's symptoms typically occur when the individual is exposed to cold or experiencing stress, not while asleep. Choice D is also incorrect as injuries limiting activity levels are not directly related to Raynaud's disease triggers.
A nurse is preparing to administer ziprasidone 10 mg IM every 6 hr. Available is ziprasidone 20 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: 0.5
Rationale: The correct answer is 0.5 mL. To calculate this, first determine the total dose needed per administration (10 mg). Then, divide the total dose by the concentration of the medication (20 mg/mL) to find the volume to administer per dose (10 mg ÷ 20 mg/mL = 0.5 mL). This ensures the patient receives the correct amount of medication. Other choices are incorrect because they do not accurately calculate the volume needed for the specified dose. For example, choosing a higher volume would result in overdosing the patient, while choosing a lower volume would underdose the patient. The correct calculation is essential to ensure the patient's safety and therapeutic effectiveness.
A client diagnosed with diverticulitis has been experiencing episodes of gastrointestinal cramping. The nurse should tell the client to maintain which type of diet during the asymptomatic period?
- A. High in carbohydrates.
- B. High in fiber.
- C. Low in residue.
- D. Low in fat.
Correct Answer: B
Rationale: The correct answer is B: High in fiber. During the asymptomatic period of diverticulitis, a high-fiber diet helps prevent diverticula formation and reduces the risk of diverticulitis flare-ups by promoting regular bowel movements and preventing constipation. Fiber also helps maintain healthy gut flora. Choices A, C, and D are incorrect as high carbohydrates may worsen symptoms, low residue may lead to constipation, and low fat is not directly related to diverticulitis management.