Nokea
A nurse is caring for a client who has dehydration due to diarrhea. Which of the following findings should the nurse report to the provider?
- A. BUN 18 mg/dL
- B. Serum creatinine 1.0 mg/dL
- C. Urine output 12 mL/hr
- D. Urine specific gravity 1.020
Correct Answer: C
Rationale: Urine output 12 mL/hr is correct. A urine output of 12 mL/hr is low and indicates oliguria, which is a concern in the context of dehydration. The normal urine output for an adult is at least 30 mL/hr. A decrease in urine output suggests that the kidneys are not receiving adequate blood flow, which could indicate severe dehydration and requires immediate attention from the provider.
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A nurse in an acute care facility is assisting with the development of an in-service about reducing environmental stressors to improve clients' sleep. Which of the following instructions should the nurse include?
- A. Turn on overhead lights briefly when checking IV lines.
- B. Open curtains between clients in semiprivate rooms.
- C. Wear shoes with rubber soles.
- D. Conduct change-of-shift report near the clients' rooms.
Correct Answer: C
Rationale: Wearing shoes with rubber soles is correct. Rubber-soled shoes reduce noise from footsteps, minimizing disturbances in client rooms and creating a quieter environment that promotes sleep.
A nurse is monitoring a client who is receiving a blood transfusion. The nurse identifies that the client has urticaria and is wheezing. Which of the following types of transfusion reactions should the nurse suspect?
- A. Anaphylactic
- B. Acute hemolytic
- C. Febrile
- D. Circulatory overload
Correct Answer: A
Rationale: An anaphylactic reaction is correct. Symptoms such as urticaria (hives) and wheezing indicate a severe allergic reaction, which can progress to anaphylaxis. This reaction is caused by a hypersensitivity to plasma proteins in the transfused blood and requires immediate intervention, including stopping the transfusion and administering epinephrine.
A nurse is reinforcing teaching with a client who is scheduled for a mammogram. Which of the following instructions should the nurse include?
- A. Wear deodorant on the day of the procedure.
- B. Avoid caffeine for 24 hours before the procedure.
- C. Schedule the procedure during your menstrual period.
- D. Do not wear jewelry during the procedure.
Correct Answer: D
Rationale: Not wearing jewelry during a mammogram prevents interference with the imaging and ensures accurate results.
A nurse is caring for a client who has a new diagnosis of Addison's disease. Which of the following findings should the nurse expect?
- A. Hypotension
- B. Weight gain
- C. Hyperglycemia
- D. Tinnitus
Correct Answer: A
Rationale: Hypotension is common in Addison's disease due to decreased cortisol and aldosterone levels affecting blood pressure regulation.
A nurse is caring for a client who has a new diagnosis of hypertension. Which of the following lifestyle modifications should the nurse recommend?
- A. Increase sodium intake.
- B. Limit physical activity.
- C. Reduce stress.
- D. Avoid calcium-rich foods.
Correct Answer: C
Rationale: Reducing stress helps lower blood pressure by decreasing sympathetic nervous system activation.