Nokea
A nurse is evaluating the 24-hr I&O records of several clients. Which of the following client findings indicates an acceptable fluid balance?
- A. Intake 2,500 mL, output 500 mL
- B. Intake 2,400 mL, output 2,500 mL
- C. Intake 1,200 mL, output 700 mL
- D. Intake 800 mL, output 2,100 mL
Correct Answer: B
Rationale: A fluid intake close to output indicates balance. Excess output or retention suggests dehydration or overload.
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A nurse is caring for a client receiving IV therapy in the left forearm and notices that the site is red, swollen, and warm. Which of the following actions should the nurse perform first?
- A. Insert an IV catheter in the opposite extremity.
- B. Discontinue the existing IV infusion.
- C. Apply warm, moist compresses to the site.
- D. Elevate the extremity.
Correct Answer: B
Rationale: The correct action is to discontinue the existing IV infusion (Choice B) first. The redness, swelling, and warmth at the IV site indicate phlebitis, which is inflammation of the vein. Discontinuing the infusion is crucial to prevent further damage and infection. This step helps to stop the irritant (IV solution) from causing more harm. Inserting an IV catheter in the opposite extremity (Choice A) does not address the current issue and may lead to the same problem. Applying warm, moist compresses (Choice C) could potentially worsen the inflammation. Elevating the extremity (Choice D) may provide some relief, but it does not address the root cause. Therefore, discontinuing the existing IV infusion is the most appropriate immediate action to take in this situation.
A nurse is caring for a client who has type I diabetes mellitus and is not adhering to guidelines for therapy. Which of the following factors should the nurse consider as contributing to the nonadherence?
- A. Gender
- B. Culture
- C. Allergies
- D. Dexterity
- E. Motivation
Correct Answer: B,D,E
Rationale: Cultural beliefs, dexterity limitations, and motivation significantly impact adherence to diabetes management.
A nurse is assisting with the admission of a client to an inpatient unit. Which of the following sources of information should the nurse use as a primary source of accurate data about the client?
- A. Client concerns
- B. Family information
- C. Medical history
- D. Progress note
Correct Answer: A
Rationale: The correct answer is A: Client concerns. This is because the client themselves is the primary source of information about their own health and well-being. By directly listening to the client's concerns, the nurse can gather accurate and firsthand information. Family information (B) may be helpful but is secondary to the client's own input. Medical history (C) is important but may not always reflect the current situation. Progress notes (D) are valuable but are based on observations and interpretations by healthcare providers. Therefore, relying on the client's concerns ensures the most accurate and up-to-date information for the admission process.
A nurse is caring for a client who has an electrical burn. With the client's permission, the nurse is answering questions from the family about his status. Which of the following responses should the nurse make?
- A. He is doing well, although he might be in the hospital for some time.
- B. He has an electrical burn. He is stable, and we will update you with any changes.
- C. He has an electrical burn, which caused coagulation of some tissues.
- D. He does not appear to have much damage and should be fine soon.
Correct Answer: B
Rationale: Providing factual and clear information about the client's condition maintains trust and transparency with the family.
A nurse is collecting data from a client who has Bell's palsy. Which of the following findings should the nurse expect? (Select all that apply.)
- A. Muscle distortion
- B. Pain behind the ear
- C. Hearing loss
- D. Facial twitching
- E. Impaired taste
Correct Answer: A,B,E
Rationale: The correct answers are A, B, and E. Bell's palsy is characterized by muscle distortion due to facial nerve paralysis, leading to asymmetry in facial expressions (A). Pain behind the ear may occur due to inflammation or compression of the facial nerve (B). Impaired taste can result from altered function of the chorda tympani nerve, affecting taste sensation on the anterior two-thirds of the tongue (E). Choices C, D, F, G are incorrect as hearing loss is not a typical feature of Bell's palsy (C), facial twitching is more characteristic of conditions like hemifacial spasm (D), and there are no specific findings associated with F and G in Bell's palsy.