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A nurse is caring for a client who has acute glomerulonephritis. Which of the following findings should the nurse expect?
- A. Oliguria
- B. Hypotension
- C. Weight loss
- D. Hematuria
Correct Answer: D
Rationale: The correct answer is D: Hematuria. In acute glomerulonephritis, there is inflammation of the glomeruli in the kidneys, leading to blood in the urine. This is due to damage to the glomerular capillaries allowing red blood cells to leak into the urine. Oliguria (A) is not a common finding as there is usually normal to increased urine output. Hypotension (B) is not typically seen as glomerulonephritis can lead to fluid overload and hypertension. Weight loss (C) is unlikely as fluid retention is common. Hematuria (D) is the hallmark finding due to the damage to glomeruli.
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A nurse is creating a plan of care for a female client who has recurrent urinary tract infections. Which of the following interventions should the nurse include in the plan?
- A. Wear loose-fitting underwear.
- B. Take a bubble bath after intercourse.
- C. Drink four 240 mL (8 oz) glasses of water each day.
- D. Void every 5 to 6 hr during the day.
Correct Answer: A
Rationale: Correct Answer: A: Wear loose-fitting underwear.
Rationale:
1. Loose-fitting underwear allows for better air circulation, reducing moisture and bacterial growth.
2. Tight clothing can create a warm, moist environment ideal for bacterial growth.
3. Preventing moisture buildup can help reduce the risk of urinary tract infections.
Summary of other choices:
B: Taking a bubble bath after intercourse can introduce bacteria into the urinary tract, increasing the risk of infection.
C: Drinking water is important for overall health but does not directly prevent urinary tract infections.
D: Voiding every 5 to 6 hours is a good practice, but it does not directly address the prevention of urinary tract infections.
A nurse is conducting health promotion education regarding contraindications to combination oral contraceptive use to a group of women. Which of the following conditions should the nurse include in the teaching?
- A. Hypertension
- B. Fibromyalgia
- C. Renal calculi
- D. Fibrocystic breast disease.
Correct Answer: A
Rationale: The correct answer is A: Hypertension. Hypertension is a contraindication to combination oral contraceptive use due to the increased risk of cardiovascular events. The estrogen component in oral contraceptives can further elevate blood pressure, leading to complications. Other choices like B: Fibromyalgia, C: Renal calculi, and D: Fibrocystic breast disease are not contraindications for oral contraceptive use. Fibromyalgia is a chronic pain condition unrelated to oral contraceptives. Renal calculi are kidney stones, which do not directly affect the safety of oral contraceptives. Fibrocystic breast disease is a benign condition and not a contraindication to oral contraceptives.
The nurse is planning care for the client. Which of the following prescriptions should the nurse anticipate the provider to prescribe?
- A. Limit alcohol intake to two drinks per day.
- B. Keep daily fat intake to less than 35%.
- C. Administer an antibiotic medication.
- D. Place on 2,300 mg sodium diet.
- E. Administer an antihypertensive medication.
- F. Limit foods high in potassium.
Correct Answer: A,D,E
Rationale: The correct answers are A, D, and E. A - Limiting alcohol intake reduces the risk of adverse health effects. D - A 2,300 mg sodium diet is beneficial for managing blood pressure. E - Antihypertensive medication helps control high blood pressure. B and F are not directly related to planning care for the client. C may not be necessary unless there is an infection present.
nurse is auscultating for crackles on a client who has pneumonia. Which of the following anterior chest wall locations should the nurse auscultate? (You will find hot spots to select in the artwork belowi. Select only the hot spot that corresponds to your answer.)
- A. A
- B. B
- C. C
- D. D
Correct Answer:
Rationale: Correct Answer: B
Rationale: Crackles in pneumonia are typically heard in the lower lung fields due to fluid accumulation. Auscultating at location B (lower anterior chest wall) allows for better detection of crackles in the bases of the lungs where pneumonia commonly affects. This area corresponds to the lower lobes where consolidation occurs, leading to crackles. Auscultating at other locations (A, C, D) may not yield clear crackle sounds associated with pneumonia.
Summary of other choices:
A (Location A - upper anterior chest wall): Crackles in pneumonia are typically heard in the lower lung fields due to fluid accumulation.
C (Location C - middle anterior chest wall): Crackles in pneumonia are not typically heard in the middle lung fields.
D (Location D - upper lateral chest wall): Crackles in pneumonia are not typically heard in the upper lateral chest wall.
A nurse is caring for a client who requires nasotracheal suctioning. Identify the sequence the nurse should follow to perform suctioning.
- A. Rinse the catheter to remove secretions.
- B. Insert the catheter during the client's inspiration.
- C. Turn on the suction and set the pressure.
- D. Don sterile gloves
- E. Apply sunction while rotating catheter
Correct Answer: D,C,B,E,A
Rationale: Correct Order: D, C, B, E, A
Rationale:
1. Don sterile gloves (D): Ensures infection control and prevents cross-contamination.
2. Turn on suction and set pressure (C): Prepares equipment and ensures proper functioning.
3. Insert catheter during client's inspiration (B): Reduces risk of inducing hypoxia.
4. Apply suction while rotating catheter (E): Maximizes removal of secretions.
5. Rinse catheter to remove secretions (A): Ensures cleanliness and prevents re-introduction of secretions.
Summary of Incorrect Choices:
- F and G are not applicable in this sequence.
- Inserting the catheter during inspiration (B) is correct, not during expiration.
- Rinsing the catheter (A) is done after suctioning, not before.