Nokea
A nurse is caring for a 3-year-old child who has had 160 mL of urine output over the past 8-hour period. The child weighs 33 lb. Which of the following actions should the nurse take? What should the nurse do for low urine output?
- A. Notify the provider.
- B. Continue to monitor the client.
- C. Perform a bladder scan at the bedside.
- D. Provide oral rehydration fluids.
Correct Answer: B
Rationale: The correct answer is B: Continue to monitor the client. In a 3-year-old child, the average expected urine output is about 1-2 ml/kg/hour. Given the child's weight of 33 lb (approximately 15 kg), the expected urine output over 8 hours would be around 120-240 ml. The child's output of 160 ml falls within this expected range, indicating adequate hydration. Therefore, the nurse should continue monitoring the client for any changes.
Incorrect choices:
A: Notifying the provider is not necessary as the urine output is within the expected range.
C: Performing a bladder scan is not indicated as there is no indication of urinary retention.
D: Providing oral rehydration fluids is not necessary since the child's urine output is adequate.
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A nurse is caring for a patient who is postoperative following a knee arthroscopy. Which of the following actions should the nurse take? Which action should the nurse take post-knee arthroscopy?
- A. Apply a warm compress to the surgical site.
- B. Keep the leg in a dependent position.
- C. Encourage weight-bearing immediately.
- D. Elevate the affected leg.
Correct Answer: D
Rationale: The correct action is to elevate the affected leg post-knee arthroscopy. Elevating the leg helps reduce swelling and promote circulation, aiding in the healing process. Keeping the leg in a dependent position (choice B) can increase swelling. Applying a warm compress (choice A) may also increase swelling. Encouraging weight-bearing immediately (choice C) can put stress on the surgical site and delay healing. Thus, elevating the affected leg is the most appropriate action in this scenario.
A nurse is providing discharge teaching for a patient who has a new prescription for warfarin. Which of the following instructions should the nurse include? What instructions should the nurse include for warfarin?
- A. Avoid foods high in vitamin K.
- B. Take the medication in the morning.
- C. Increase intake of vitamin C.
- D. Use a hard-bristled toothbrush.
Correct Answer: A
Rationale: The correct answer is A: "Avoid foods high in vitamin K." Warfarin is a blood thinner that works by decreasing the blood's ability to clot. Vitamin K can counteract the effects of warfarin, so patients should avoid consuming large amounts of foods high in vitamin K, such as leafy greens. This instruction is crucial to ensure the medication's effectiveness and prevent complications like blood clots. Taking warfarin in the morning (B) or increasing vitamin C intake (C) does not directly impact its effectiveness. Using a hard-bristled toothbrush (D) can increase the risk of bleeding gums but is not a primary concern with warfarin therapy.
A nurse is preparing to administer furosemide 40 mg IV. Available is furosemide 10 mg/1 mL. How many mL should the nurse administer per dose? How many mL of furosemide should the nurse administer?
Correct Answer: 4
Rationale: The correct answer is 4 mL. To determine this, the nurse uses the formula: Desired dose (40 mg) ÷ Stock strength (10 mg/1 mL) = mL to administer. Thus, 40 mg ÷ 10 mg/1 mL = 4 mL. This calculation ensures the proper dosage is given. Other choices are incorrect because they do not follow the correct dosage calculation based on the given information.
A nurse is caring for a patient and notices that the patient's urine is dark amber, cloudy, and has an unpleasant odor. Which of the following conditions should the nurse associate these findings with? Which condition is associated with dark, cloudy, odorous urine?
- A. Urinary retention
- B. Urinary incontinence
- C. Urinary tract infection
- D. Urinary frequency
Correct Answer: C
Rationale: The correct answer is C: Urinary tract infection (UTI). Dark amber, cloudy, and odorous urine are common indicators of a UTI. The dark amber color may suggest the presence of blood or concentrated urine due to the infection. Cloudiness can result from the presence of bacteria, white blood cells, or other particles in the urine. The unpleasant odor is often caused by the presence of bacteria breaking down waste products in the urine. Urinary retention (A) usually presents with difficulty emptying the bladder, not changes in urine appearance. Urinary incontinence (B) refers to involuntary leakage of urine and is not typically associated with changes in urine characteristics. Urinary frequency (D) involves frequent urination but does not necessarily cause changes in urine appearance.
A nurse is instructing a patient who has just been prescribed bumetanide. What should the nurse include in the instructions? What should the nurse include in bumetanide instructions?
- A. Take the prescribed second dose at nighttime.
- B. Limit your fluid intake to no more than 1.5 L a day.
- C. Report any changes in hearing.
- D. Avoid foods high in potassium.
Correct Answer: C
Rationale: The correct answer is C: Report any changes in hearing. Bumetanide is a loop diuretic that can cause ototoxicity, leading to changes in hearing. Instructing the patient to report any changes in hearing is crucial to monitor for potential adverse effects. Choice A is incorrect as bumetanide is usually taken once daily in the morning to prevent nocturia. Choice B is incorrect as the patient may need to increase fluid intake to prevent dehydration. Choice D is incorrect as bumetanide can lead to hypokalemia, so foods high in potassium may be beneficial.