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A nurse is assisting with the admission of a client who is dehydrated. Which of the following BUN levels should the nurse expect the client to have?
- A. 3.6 mg/dL
- B. 9 mg/dL
- C. 18.7 mg/dL
- D. 24 mg/dL
Correct Answer: D
Rationale: The correct answer is D: 24 mg/dL. BUN (Blood Urea Nitrogen) levels typically increase in dehydration due to reduced kidney perfusion. A BUN level of 24 mg/dL is higher than normal (7-20 mg/dL) and is indicative of dehydration. Choice A (3.6 mg/dL) is too low for a dehydrated client. Choice B (9 mg/dL) is within the normal range and not high enough for dehydration. Choice C (18.7 mg/dL) is slightly elevated but may not be as indicative of dehydration as choice D.
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A nurse is caring for a client who is to undergo surgery the next day. The client tells the nurse, 'I'm afraid of what's going to happen.' Which of the following responses should the nurse make?
- A. Assure the client that the surgery is safe and complications are rare.
- B. Encourage the client to discuss her fears further.
- C. Inform the client that she has an excellent provider and has nothing to worry about.
- D. Explain to the client that anxiety can prolong hospitalization.
Correct Answer: B
Rationale: Encouraging the client to talk about their fears provides emotional support and can reduce anxiety.
A nurse is caring for an older adult client who reports occasional constipation. The nurse should inform the client that straining while defecating can cause which of the following?
- A. Dilated pupils
- B. Dysrhythmias
- C. Diarrhea
- D. Gastric ulcer
Correct Answer: B
Rationale: The correct answer is B: Dysrhythmias. Straining while defecating can increase intra-abdominal pressure, leading to a vagal response that triggers dysrhythmias in susceptible individuals. This can be particularly dangerous for older adults with underlying heart conditions. Dilated pupils (choice A) are not directly related to straining during defecation. Diarrhea (choice C) is the opposite of constipation and is not a common consequence of straining. Gastric ulcers (choice D) are typically caused by factors such as H. pylori infection or NSAID use, not straining during defecation.
A nurse is collecting data from the mother of a toddler. Which of the following activities should the nurse expect the toddler to be able to perform?
- A. Jump rope
- B. Ride a tricycle
- C. Print letters and numbers
- D. Use scissors to cut out a picture
Correct Answer: B
Rationale: The correct answer is B: Ride a tricycle. Toddlers typically develop the coordination and balance needed to ride a tricycle around the age of 3. This activity helps improve gross motor skills and coordination. Jumping rope (A) requires more advanced motor skills and coordination. Printing letters and numbers (C) involves fine motor skills that develop later. Using scissors to cut out a picture (D) also requires more advanced fine motor skills and hand-eye coordination.
A nurse is reinforcing teaching with a client who has fibrocystic breast changes about dietary changes that can help minimize symptoms. Which of the following dietary elements should the nurse instruct the client to limit?
- A. Fat
- B. Water
- C. Calcium
- D. Vitamin E
Correct Answer: A
Rationale: A diet low in fat has been shown to help reduce fibrocystic breast pain and discomfort.
A nurse is planning to perform passive range of motion for a client who is immobilized. Which of the following actions should the nurse plan to take?
- A. Move body parts rapidly through the movements.
- B. Support extremities above and below joints.
- C. Stretch the body part just beyond the existing range of motion.
- D. Continue moving body parts if muscle spasticity occurs.
Correct Answer: B
Rationale: The correct answer is B: Support extremities above and below joints. This is because supporting the extremities above and below the joints helps to maintain proper alignment and stability during passive range of motion exercises, preventing injury and ensuring effective movement. Moving body parts rapidly (choice A) can cause muscle strain or injury. Stretching the body part beyond existing range (choice C) can lead to muscle or ligament damage. Continuing movement if spasticity occurs (choice D) can exacerbate muscle tightness. This is why choice B is the most appropriate action to take during passive range of motion exercises.