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A nurse is emptying a client's urinal when she notices the urine is dark amber, cloudy, and has an unpleasant odor. The nurse should identify that these findings are likely to be the result of which of the following?
- A. Urinary tract infection.
- B. Dehydration.
- C. Kidney stones.
- D. Liver disease.
Correct Answer: A
Rationale: Dark amber, cloudy urine with an unpleasant odor is commonly caused by a urinary tract infection due to bacterial inflammation and pus in the urine.
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A nurse is preparing to administer morphine 15 mg subcutaneously. The amount available is morphine injection 10 mg/mL. How many mL should the nurse administer? (Round to the nearest tenth. Use a leading zero if it applies. (Do not use a trailing zero))
Correct Answer: 1.5 mL
Rationale: 15 mg ÷ 10 mg/mL = 1.5 mL. The nurse should administer 1.5 mL.
A nurse is providing care for an older adult client who has hyperglycemia, polydipsia, and polyuria. Which of the following manifestations supports the clinical presentation of hyperosmolar hyperglycemic syndrome (HHS)? (Select All that Apply.)
- A. Acetone breath.
- B. Fever.
- C. Serum glucose 800 mg/dL (74 to 106 mg/dL).
- D. Serum bicarbonate 15 mEq/L (21 to 28 mEq/L).
- E. Insidious onset.
Correct Answer: B,C,E
Rationale: Fever, serum glucose of 800 mg/dL, and insidious onset are characteristic of HHS, often triggered by infection and marked by extreme hyperglycemia without significant ketoacidosis.
A nurse is collecting data from a client whose arterial blood gas values reveal a pH of 7.24, PaCO₂ of 53, and an HCO₃ of 24. The nurse should prepare to treat the client for which of the following acid-base imbalances?
- A. Metabolic acidosis.
- B. Metabolic alkalosis.
- C. Respiratory acidosis.
- D. Respiratory alkalosis.
Correct Answer: C
Rationale: Low pH (7.24) and high PaCO₂ (53) indicate respiratory acidosis due to CO₂ accumulation from inadequate ventilation.
An adult client newly diagnosed with type 2 diabetes mellitus asks a nurse to explain how he developed the condition. Which of the following responses should the nurse make?
- A. Your body will continue producing too much insulin without medicine to counteract it.
- B. Your body doesn't process glucose well.
- C. Your body's hemoglobin is not binding to the sugar you consume.
- D. Your body's immune system has destroyed cells in your pancreas.
Correct Answer: B
Rationale: Type 2 diabetes involves insulin resistance, where the body cannot process glucose effectively, leading to elevated blood glucose levels.
A nurse is preparing to administer ondansetron 4 mg IM stat. The amount available is ondansetron for injection 2 mg/mL. How many mL should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. (Do not use a trailing zero))
Correct Answer: 2 mL
Rationale: 4 mg ÷ 2 mg/mL = 2 mL. The nurse should administer 2 mL.