Nokea
A nurse is caring for a client who is receiving oxygen therapy via nasal cannula. Which of the following actions should the nurse take?
- A. Apply petroleum jelly to the nares.
- B. Secure the cannula with tape on the forehead.
- C. Check the nares for irritation.
- D. Increase the flow rate if the client reports dryness.
Correct Answer: C
Rationale: Checking the nares for irritation ensures early detection of skin breakdown from prolonged cannula use.
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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.
A nurse is caring for a client who has a new diagnosis of pancreatitis. Which of the following findings should the nurse expect?
- A. Epigastric pain
- B. Weight gain
- C. Bradycardia
- D. Hypotension
Correct Answer: A
Rationale: Epigastric pain is a hallmark symptom of pancreatitis due to inflammation of the pancreas.
A nurse is caring for a client who has a new prescription for lamotrigine. Which of the following adverse effects should the nurse monitor for?
- A. Skin rash
- B. Weight gain
- C. Bradycardia
- D. Hypoglycemia
Correct Answer: A
Rationale: Lamotrigine, an anticonvulsant, can cause a skin rash, which may indicate a serious reaction like Stevens-Johnson syndrome.
A nurse is reinforcing teaching with a client who is scheduled for a cardiac MRI. Which of the following instructions should the nurse include?
- A. Remove all metal objects before the procedure.
- B. Fast for 12 hours before the procedure.
- C. Expect to receive general anesthesia.
- D. Avoid drinking fluids after the procedure.
Correct Answer: A
Rationale: Removing all metal objects is essential for safety during an MRI, as magnetic fields can interact with metal.
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.