Nokea
A nurse is documenting client care. Which of the following entries should the nurse identify as an example of implementation of client care?
- A. Contacted the provider to report client findings
- B. Administered medications as prescribed
- C. Reviewed the client's lab results
- D. Discussed the care plan with the family
Correct Answer: B
Rationale: Documenting that medications were administered as prescribed is an example of the implementation of client care.
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A nurse is reviewing the lab report of a client who has been experiencing a fever for the last 3 days. What lab result indicates the client is experiencing fluid volume deficit (FVD)?
- A. Decreased hematocrit
- B. Increased BUN
- C. Increased hematocrit
- D. Decreased urine specific gravity
Correct Answer: C
Rationale: An increased hematocrit level indicates dehydration or fluid volume deficit.
A nurse is reviewing the medical records of a group of older adult clients. The nurse should identify which of the following as a risk factor for developing infections?
- A. Increased physical activity
- B. Lowered immune system function
- C. Regular health screenings
- D. Proper nutrition
Correct Answer: B
Rationale: Lowered immune system function in older adults increases susceptibility to infections.
A nurse is caring for a client who has an indwelling urinary catheter. What should the nurse identify as a sign of catheter occlusion?
- A. Bladder distention
- B. Frequent urination
- C. Dark urine
- D. Increased thirst
Correct Answer: A
Rationale: Bladder distention indicates the inability to empty the bladder, which can be a sign of catheter occlusion.
A nurse finds a client on the floor of their room experiencing a seizure. Which of the following actions is the nurse's priority?
- A. Place the client on their side with their head forward
- B. Call for help
- C. Protect the client's head
- D. Restrain the client
Correct Answer: A
Rationale: Placing the client on their side with their head forward helps maintain an open airway and prevents aspiration.
A nurse is monitoring a client who has been receiving intermittent enteral feedings. What should the nurse identify as an intolerance to the feeding?
- A. Increased appetite
- B. Nausea
- C. Weight gain
- D. Regular bowel movements
Correct Answer: B
Rationale: Nausea is a sign of intolerance to enteral feedings, which may also include vomiting and dumping syndrome.