Nokea
A nurse is collecting data from a client. Which of the following findings should the nurse report to the charge nurse as an indicator of dehydration?
- A. Red mucous membranes
- B. Jugular vein distention
- C. Skin tenting
- D. BP 178/90 mm Hg
Correct Answer: C
Rationale: Skin tenting is a hallmark sign of dehydration due to decreased skin elasticity. Jugular vein distention and high BP indicate fluid overload.
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A nurse is caring for a client who has respiratory acidosis. Which of the following pH levels should the nurse expect?
- A. pH 7.31
- B. pH 7.39
- C. pH 7.48
- D. pH 7.50
Correct Answer: A
Rationale: The correct answer is A: pH 7.31. In respiratory acidosis, there is an excess of carbon dioxide in the blood, leading to decreased pH. Normal pH range is 7.35-7.45. pH 7.31 indicates acidosis. Choice B is within the normal range, C and D are alkalotic, and E, F, G are not provided. pH 7.31 is the most accurate representation of respiratory acidosis in this scenario.
While auscultating a client's heart sounds, the nurse hears turbulence between S1 and S2. The nurse should document this finding as which of the following?
- A. A systolic murmur
- B. A third heart sound (S3)
- C. An expected heart sound
- D. A fourth heart sound (S4)
Correct Answer: A
Rationale: The correct answer is A: A systolic murmur. Turbulence between S1 and S2 indicates a heart sound occurring during systole. Systolic murmurs are abnormal heart sounds heard between S1 and S2, often indicating a problem with the heart valves. S3 and S4 heart sounds occur after S2 and are associated with ventricular filling abnormalities. An expected heart sound would not exhibit turbulence. Therefore, the correct choice is A.
A nurse is preparing a client for magnetic resonance imaging (MRI). Which of the following statements should the nurse include when reinforcing teaching?
- A. You'll have to remove metal objects such as watches and body jewelry.
- B. Your exposure to radiation will be minimal.
- C. You will not be able to talk to the technician during the procedure.
- D. Unlike an x-ray, the MRI allows you to move around a bit.
Correct Answer: A
Rationale: The correct answer is A: You'll have to remove metal objects such as watches and body jewelry. This is important for MRI safety as the magnetic field can interact with metal objects, causing harm or image distortion. Removing metal ensures the client's safety during the procedure. Choice B is incorrect as MRI does not involve radiation exposure but magnetic fields. Choice C is incorrect as communication with the technician is usually possible through an intercom system. Choice D is incorrect as clients must remain still during an MRI to prevent image blurring.
A nurse is preparing to measure a client's oral temperature. The client states that he has just had some ice chips in his mouth. Which of the following actions should the nurse take?
- A. Wait 30 min and return to measure the client's oral temperature.
- B. Provide the client a sip of warm water and wait 5 min before measuring his oral temperature.
- C. Document the inability to obtain an accurate reading of the client's oral temperature.
- D. Proceed to measure the client's oral temperature.
Correct Answer: A
Rationale: The correct answer is A: Wait 30 min and return to measure the client's oral temperature. When a client consumes ice chips, it can significantly lower their oral temperature, leading to an inaccurate reading. Waiting for 30 minutes allows the ice chips to melt and the oral temperature to stabilize. Providing warm water (choice B) may not be effective in raising the oral temperature quickly enough for an accurate reading. Documenting the inability to obtain an accurate reading (choice C) is not proactive in ensuring accurate assessment. Proceeding to measure the client's oral temperature (choice D) without allowing time for the ice chips to melt will likely result in an inaccurate reading.
A nurse is collecting data from a client who is receiving intermittent enteral feedings. Which of the following laboratory values should the nurse identify as an indication that the client needs a change in the formula?
- A. Hematocrit 42%
- B. Urine specific gravity 1.022
- C. BUN 28 mg/dL
- D. Sodium 142 mEq/L
Correct Answer: C
Rationale: The correct answer is C: BUN 28 mg/dL. An elevated BUN level indicates poor protein metabolism, which could be a sign that the current enteral formula is not being adequately utilized by the client. This could lead to malnutrition or other complications.
A: Hematocrit measures the volume percentage of red blood cells in blood. It is not directly related to enteral feedings.
B: Urine specific gravity reflects hydration status and kidney function, not related to enteral feedings.
D: Sodium level is not specific to enteral feedings.
In summary, an elevated BUN level signifies poor protein metabolism and indicates a need for a change in the enteral formula to better meet the client's nutritional needs.