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A nurse is caring for a client who has a prescription for furosemide. Which of the following findings should the nurse identify as an indication that the medication is effective?
- A. Weight loss of 0.5 kg (1.1 lb) in 24 hours.
- B. Increased urinary output.
- C. Blood pressure of 118/78 mm Hg.
- D. Decreased peripheral edema.
Correct Answer: A
Rationale: The correct answer is A. Weight loss of 0.5 kg (1.1 lb) in 24 hours is an indication that furosemide is effectively reducing fluid retention. This medication works by promoting diuresis, resulting in increased urine output, which could lead to weight loss. While increased urinary output (choice B) is a common effect of furosemide, weight loss is a more specific indicator of its effectiveness. Blood pressure (choice C) and decreased peripheral edema (choice D) can be influenced by various factors and are not direct indicators of furosemide's effectiveness in reducing fluid retention.
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A nurse is teaching a newly licensed nurse about therapeutic techniques to use when leading a group on a mental health unit. Which of the following group facilitation techniques should the nurse include in the teaching?
- A. Share personal opinions to help influence the group's values.
- B. Measure the accomplishments of the group against a previous group.
- C. Yield in situations of conflicts to maintain group harmony.
- D. Use modeling to help the clients improve their interpersonal skills.
Correct Answer: D
Rationale: The correct answer is D: 'Use modeling to help the clients improve their interpersonal skills.' Modeling is an effective therapeutic technique where the leader demonstrates appropriate behaviors for the group to learn from. This technique can help clients improve their interpersonal skills by observing and replicating positive behaviors. Choices A, B, and C are incorrect. Sharing personal opinions to influence the group's values may not be appropriate as it could hinder the group dynamics and individual autonomy. Comparing accomplishments against a previous group is not a recommended technique as each group is unique, and comparisons may not be beneficial. Yielding in conflicts to maintain group harmony may lead to unresolved issues and hinder the group's progress.
A nurse is assessing a client who has cirrhosis. Which of the following findings should the nurse expect?
- A. Clay-colored stools.
- B. Hypertension.
- C. Stridor.
- D. Elevated temperature.
Correct Answer: A
Rationale: Clay-colored stools are a classic finding in a client with cirrhosis. Cirrhosis can lead to impaired bile flow, resulting in pale or clay-colored stools due to a lack of bilirubin in the stool. Hypertension, stridor, and elevated temperature are not typically associated with cirrhosis. Hypertension may occur in cirrhosis but is not a consistent finding, stridor is more commonly associated with upper airway obstruction, and elevated temperature may indicate an infection rather than a direct result of cirrhosis.
A nurse is assessing a client who has chronic obstructive pulmonary disease (COPD). Which of the following findings should the nurse expect?
- A. Increased oxygen saturation with exercise.
- B. Pursed-lip breathing with exertion.
- C. Productive cough with clear sputum.
- D. Clubbing of the fingers.
Correct Answer: C
Rationale: The correct answer is C: 'Productive cough with clear sputum.' Clients with COPD often have a chronic productive cough with thick, often purulent sputum. This sputum can be white, yellow, green, or clear. Choices A, B, and D are incorrect. Oxygen saturation may decrease with exertion in COPD due to impaired gas exchange. Pursed-lip breathing is used to control dyspnea, not directly related to increased saturation with exercise. Clubbing of the fingers is typically seen in conditions such as cyanotic heart disease or lung cancer.
A client, 12 hours postpartum, reports not having a bowel movement for 4 days. Which medication should the nurse administer?
- A. Bisacodyl 10 mg rectal suppository.
- B. Magnesium hydroxide 30 ml PO.
- C. Famotidine 20 mg PO.
- D. Loperamide 4 mg PO.
Correct Answer: A
Rationale: In this scenario, the nurse should administer Bisacodyl 10 mg rectal suppository. The client's report of not having a bowel movement for 4 days indicates constipation, and Bisacodyl is a stimulant laxative that helps initiate bowel movements. Magnesium hydroxide is an antacid and osmotic laxative used for indigestion, not for constipation. Famotidine is an H2 receptor antagonist used to reduce stomach acid production and treat heartburn, not constipation. Loperamide is an antidiarrheal agent and would be contraindicated in a client experiencing constipation.
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.