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A nurse is collecting data from a client who has dehydration. Which of the following findings should the nurse expect?
- A. Cool skin
- B. Bradycardia
- C. Urine output 20 mL/hr
- D. Sodium 142 mEq/L
Correct Answer: C
Rationale: The correct answer is C: Urine output 20 mL/hr. In dehydration, the body tries to conserve water, leading to decreased urine output. This finding indicates the body's attempt to retain fluids. A: Cool skin is incorrect as dehydration often presents with warm, dry skin due to decreased sweating. B: Bradycardia is unlikely in dehydration as the body tries to maintain cardiac output by increasing heart rate. D: A normal sodium level of 142 mEq/L does not specifically indicate dehydration.
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A nurse is assisting with a presentation at a senior center regarding age-related changes. Which of the following should the nurse include?
- A. Decreased muscle mass
- B. Thickened vertebral disks
- C. Decreased chest width
- D. Increased force of isometric contractions
Correct Answer: A
Rationale: The correct answer is A: Decreased muscle mass. With aging, there is a natural decline in muscle mass known as sarcopenia. The nurse should include this because it is a common age-related change that can affect strength and mobility in older adults. Decreased muscle mass can lead to frailty and increased risk of falls. Thickened vertebral disks (B) are not a typical age-related change; instead, they tend to degenerate and become thinner. Decreased chest width (C) is not a significant age-related change and may vary among individuals. Increased force of isometric contractions (D) is not a typical age-related change; in fact, muscle strength tends to decrease with age, leading to reduced force production.
A nurse manager is talking with a nurse who was unable to sleep the previous night after participating in an unsuccessful client resuscitation. Which of the following responses should the nurse manager make?
- A. Tell me what your concerns are.'
- B. Maybe you should schedule an appointment with a psychiatrist.'
- C. It's hard at first, but you will get used to these things.'
- D. Don't worry. We all go through these feelings. They will pass.'
Correct Answer: A
Rationale: Encouraging the nurse to express concerns supports emotional well-being and prevents burnout.
A nurse is preparing to suction the airway of a client who has a tracheostomy. Identify the sequence of actions the nurse should take after performing hand hygiene.
- A. Adjust the suction to 120 to 150 mm Hg.
- B. Apply intermittent suction while rotating the catheter.
- C. Don sterile gloves.
- D. Check the function of the suction catheter.
- E. Insert the catheter without suction.
- F. Hyperoxygenate the client.
- G. Check for secretion clearance.
Correct Answer: A,F,D,C,E,B
Rationale: Check for secretion clearance.
A nurse in a provider's office is caring for a client who has tinea pedis. Which of the following findings should the nurse expect?
- A. Recent exposure to poison ivy
- B. Scaling and redness between the toes
- C. Circular, erythematous patches on the scalp
- D. A recent prescription for an antiseizure medication
Correct Answer: B
Rationale: Tinea pedis, or athlete's foot, commonly presents as scaling and redness between the toes due to fungal infection.
A nurse is caring for a client who ingested a poison and is now having seizures. Which of the following is the priority action the nurse should take?
- A. Maintain the patency of the client's airway.
- B. Identify the poison the client ingested.
- C. Measure the client's blood pressure.
- D. Position the client on her side.
Correct Answer: A
Rationale: Airway patency is the priority during seizures to prevent aspiration and ensure adequate oxygenation.