Nokea
A nurse is caring for a pregnant patient in her third trimester. Which of the following findings should be reported immediately?
- A. Mild edema in the lower extremities
- B. Heartburn
- C. Severe headache and visual disturbances
- D. Frequent urination
Correct Answer: C
Rationale: Severe headache and visual disturbances suggest preeclampsia, a medical emergency. Mild edema, heartburn, and frequent urination are normal in late pregnancy.
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The nurse is caring for a 10 year-old on admission to the burn unit. One assessment parameter that will indicate that the child has adequate fluid replacement is
- A. Urinary output of 30 ml per hour
- B. No complaints of thirst
- C. Increased hematocrit
- D. Good skin turgor around burn
Correct Answer: A
Rationale: Urinary output of 30 ml per hour. This indicates adequate fluid replacement without suggesting overload.
The nurse is teaching a client with chronic obstructive pulmonary disease (COPD) about energy conservation. Which of the following strategies should the nurse recommend?
- A. Perform all activities in the morning when energy is highest.
- B. Use a shower chair when bathing.
- C. Avoid using a pursed-lip breathing technique.
- D. Walk quickly to complete tasks efficiently.
Correct Answer: B
Rationale: Using a shower chair conserves energy by reducing exertion during bathing, a taxing activity for COPD patients. Morning activity (A) may not suit all, pursed-lip breathing (C) aids respiration, and quick walking (D) increases oxygen demand.
The nurse understands that the patient with esophageal varices should not be given food such as:
The nurse understands that the patient with esophageal varices should not be given food such as:
- A. Crackers
- B. Purred food
- C. Liquid
- D. Soft
Correct Answer: A
Rationale: Crackers, being rough, can irritate or rupture fragile esophageal varices.
The physician has ordered IV replacement of potassium for a patient with severe hypokalemia.
The nurse would administer the IV potassium
- A. by rapid bolus.
- B. diluted in 100 cc over 1 hour.
- C. diluted in 10 cc over 10 minutes.
- D. IV push.
Correct Answer: B
Rationale: Potassium is diluted and infused slowly to prevent cardiac arrhythmias.
Liquid iron preparation
Liquid iron preparation, which of the following directions would be appropriate for the nurse to teach?
- A. Administer at least one hour before meals.
- B. Inform the patient about the loose stools.
- C. Liquid iron must be taken with a straw.
- D. Avoid juices with iron.
Correct Answer: C
Rationale: Using a straw prevents tooth staining from liquid iron.