Nokea
A nurse is caring for four clients who have drainage tubes. The nurse should identify the client who has which of the following tubes as being at risk for hypokalemia?
- A. An NG tube to suction
- B. An indwelling urinary catheter to gravity drainage
- C. A chest tube to water-seal drainage
- D. A nephrostomy tube to a drainage bag
Correct Answer: A
Rationale: NG suction removes gastric contents, leading to loss of potassium and increased risk of hypokalemia.
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A nurse in a provider's office is reinforcing teaching with a client who is to collect a 24-hr urine specimen. Which of the following instructions should the nurse include in the teaching?
- A. At the beginning of the collection time, urinate and then discard the urine.
- B. Keep the collection container at room temperature.
- C. Save each urine collection in a separate container.
- D. At the end of the collection time, urinate and save the urine in a separate container.
Correct Answer: A
Rationale: Correct Answer: A
Rationale: Urinating and discarding the first urine sample helps ensure that the 24-hour collection period begins accurately. This initial voiding clears out any urine that has been in the bladder prior to the start of the collection. This step is crucial to obtain an accurate measurement of substances excreted over the 24-hour period.
Summary:
B: Keeping the collection container at room temperature is not crucial for accurate urine collection.
C: Saving each urine collection in a separate container may lead to inaccuracies in the final analysis.
D: Urinating and saving the final urine sample separately at the end of the collection period may skew the results.
A nurse is planning home care for a school-age child who is awaiting discharge to home following an acute asthma attack. Which of the following growth and development stages according to Erikson should the nurse consider in the planning?
- A. Autonomy vs. shame and doubt
- B. Initiative vs. guilt
- C. Industry vs. inferiority
- D. Identity vs. role confusion
Correct Answer: C
Rationale: The correct answer is C: Industry vs. inferiority. This stage in Erikson's theory occurs during school age (6-11 years), where children develop a sense of competence and mastery in their skills and tasks. Considering this stage in the planning for a child recovering from an asthma attack is crucial. By emphasizing the child's abilities and encouraging them to engage in self-care activities, the nurse can promote a sense of industry and competence, which can boost the child's self-esteem. Choices A, B, and D are not directly related to the developmental stage of school-age children and do not address the specific needs and challenges this age group faces. Autonomy vs. shame and doubt (A) is more relevant to toddlers, Initiative vs. guilt (B) is more relevant to preschoolers, and Identity vs. role confusion (D) is more relevant to adolescents.
A nurse is assisting with the preparation of a presentation at a community center about complementary and alternative therapies. Which of the following therapies should the nurse describe as the use of an electronic monitoring device to help clients learn to control physical responses?
- A. Reiki
- B. Biofeedback
- C. Acupuncture
- D. Yoga
Correct Answer: B
Rationale: Biofeedback uses electronic monitoring to help individuals gain control over physiological functions such as heart rate and muscle tension.
A nurse is collecting data for a client who has malnutrition resulting from a chronic illness. Which of the following manifestations should the nurse expect to find?
- A. Non-palpable spleen
- B. Slightly moist skin
- C. Presence of surface papillae on tongue
- D. Depigmented hair
Correct Answer: D
Rationale: The correct answer is D: Depigmented hair. Malnutrition can lead to changes in hair color and texture, resulting in depigmented or thinning hair. This is due to the body lacking essential nutrients needed for healthy hair growth. Non-palpable spleen (A) is not typically associated with malnutrition. Slightly moist skin (B) is more likely to be seen in a well-nourished individual. Presence of surface papillae on the tongue (C) is not a common manifestation of malnutrition. Therefore, depigmented hair (D) is the most likely manifestation of malnutrition in this scenario.
A nurse is caring for an older adult client who has constipation. Which of the following actions should the nurse take?
- A. Request that the provider prescribe a stool softener.
- B. Promote active range-of-motion activities.
- C. Add fluid and fiber to the diet.
- D. Avoid gas-producing foods.
Correct Answer: C
Rationale: The correct answer is C: Add fluid and fiber to the diet. Increasing fluid intake helps soften the stool, making it easier to pass. Fiber adds bulk to the stool, promoting regular bowel movements. This is a non-invasive and effective intervention for constipation in older adults. Requesting a stool softener (A) may be considered if dietary interventions are ineffective. Promoting active range-of-motion activities (B) may help prevent constipation but is not the first-line intervention. Avoiding gas-producing foods (D) is not directly related to treating constipation.