Nokea
A nurse is caring for a client who has gastroenteritis. Which of the following assessment findings should the nurse recognize as an indication that the client is experiencing dehydration?
- A. Distended jugular veins
- B. Increased blood pressure
- C. Decreased blood pressure
- D. Pitting, dependent edema
Correct Answer: C
Rationale: The correct answer is C: Decreased blood pressure. Dehydration in a client with gastroenteritis results in a decrease in blood volume, leading to decreased blood pressure. When the body loses fluids through vomiting and diarrhea, there is a reduction in circulating blood volume, causing a drop in blood pressure. This can result in symptoms such as dizziness, weakness, and increased heart rate as the body tries to compensate for the reduced blood volume. Distended jugular veins (A) are more indicative of heart failure, increased blood pressure (B) can occur in conditions like hypertension or stress, and pitting, dependent edema (D) is a sign of fluid overload, not dehydration.
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A nurse is caring for a client receiving TPN. Which of the following actions should the nurse take?
- A. Monitor serum blood glucose during infusion.
- B. Obtain the client's weight daily.
- C. Infuse 0.9% sodium chloride if the solution is not available.
- D. Verify the solution with another RN prior to infusion.
Correct Answer: A
Rationale: The correct answer is A: Monitor serum blood glucose during infusion. This is crucial because TPN (total parenteral nutrition) is a high concentration of glucose and can lead to hyperglycemia. Regular monitoring helps in detecting and managing any glucose fluctuations promptly. Choice B is incorrect as daily weight is essential but not the priority when compared to monitoring glucose. Choice C is incorrect as infusing 0.9% sodium chloride as an alternative can lead to incompatible solutions and cause harm. Choice D is incorrect because verifying the solution with another RN is important for safety but does not address the immediate need for glucose monitoring.
A nurse is teaching a client who has a new prescription for warfarin about foods that affect the INR. The nurse should include in the teaching that which of the following foods interacts with this medication?
- A. Orange juice
- B. Cabbage
- C. Beef stew
- D. Vegetable oil
Correct Answer: B
Rationale: The correct answer is B: Cabbage. Cabbage is high in vitamin K, which can counteract the effects of warfarin, a medication that works by blocking the action of vitamin K in the blood. Consuming large amounts of foods high in vitamin K, like cabbage, can decrease the effectiveness of warfarin and increase the risk of blood clots. Orange juice (A), beef stew (C), and vegetable oil (D) do not significantly affect INR levels or interact with warfarin in the same way as vitamin K-rich foods like cabbage.
A nurse is providing teaching to a client who is considering a total hip arthroplasty. The client asks the nurse, 'What happens if I need a blood transfusion during my surgery?' Which of the following statements should the nurse make?
- A. You will need to choose a family member to donate blood, instead of a friend.'
- B. This surgery has minimal blood loss, so you will not require a transfusion.'
- C. You can donate your own blood a few weeks prior to this surgery.'
- D. Using screened donor blood during a transfusion makes it unlikely that you would have an infusion reaction.'
Correct Answer: C
Rationale: The correct answer is C: "You can donate your own blood a few weeks prior to this surgery." This is the best option because it addresses the client's concern about needing a blood transfusion during surgery by suggesting an effective proactive measure. Donating your own blood before surgery, known as autologous donation, ensures that you have your own blood available if needed, reducing the risk of transfusion reactions and complications. It allows for a personalized and safe option in case of blood loss during the procedure.
As for the other options:
A: This statement does not provide relevant information about blood transfusions.
B: This statement is inaccurate as total hip arthroplasty can result in significant blood loss requiring a transfusion.
D: While using screened donor blood reduces the risk of infusion reactions, it does not address the client's specific concern about needing a transfusion during surgery.
Therefore, option C is the most appropriate response as it directly addresses the client's query and offers a practical solution.
A nurse is caring for a client who has an arteriovenous graft. Which of the following findings indicates adequate circulation of the graft?
- A. Palpable thrill
- B. Memorantake blood pressure
- C. Absence of a bruit
- D. Dilated appearance of the graft
Correct Answer: A
Rationale: The correct answer is A: Palpable thrill. A palpable thrill indicates that there is adequate circulation of the arteriovenous graft. A thrill is a vibration felt over the graft site, which suggests that blood is flowing through the graft properly. A palpable thrill is a positive sign of good circulation.
The other choices are incorrect because:
B: Membranous blood pressure does not provide information about the circulation of the graft.
C: Absence of a bruit could indicate decreased or absent blood flow through the graft.
D: Dilated appearance of the graft does not necessarily indicate adequate circulation; it could be due to other reasons such as infection or inflammation.
A nurse is assessing a client who has anorexia. Which of the following findings should the nurse identify as a manifestation of malnutrition?
- A. Dry skin
- B. Alopecia
- C. Increased salivation
- D. Dolichocephaly
Correct Answer: A
Rationale: The correct answer is A: Dry skin. Malnutrition can lead to a deficiency in essential nutrients like vitamins and minerals, causing skin to become dry and flaky. This occurs due to a lack of proper hydration and nourishment. Alopecia (B) is more commonly associated with conditions like stress or hormonal imbalances. Increased salivation (C) is not typically linked to malnutrition but can be seen in conditions like GERD. Dolichocephaly (D) refers to an elongated shape of the head and is not directly related to malnutrition. In summary, dry skin is a manifestation of malnutrition due to the lack of essential nutrients, while the other choices are more likely associated with different conditions or factors.