Nokea
A nurse is monitoring a client who was admitted with a severe burn injury and is receiving IV fluid resuscitation therapy. The nurse should identify a decrease in which of the following findings as an indication of adequate fluid replacement?
- A. Blood pressure
- B. Heart rate
- C. Urine output
- D. Respiratory rate
Correct Answer: B
Rationale: The correct answer is B: Heart rate. A decrease in heart rate indicates adequate fluid replacement in a burn-injured patient due to improved cardiac output and perfusion. When fluid resuscitation is effective, the heart doesn't need to work as hard to maintain circulation. Blood pressure (choice A) may fluctuate initially but is not a reliable indicator of fluid replacement alone. Urine output (choice C) is important but may take time to stabilize. Respiratory rate (choice D) may be affected by pain or stress, not solely fluid status. Other choices are not relevant.
You may also like to solve these questions
A nurse is teaching self-management to a client who has hepatitis B. Which of the following instructions should the nurse include in the teaching?
- A. Rest frequently throughout the day.
- B. Increase physical activity gradually.
- C. Take medication with meals.
- D. Drink fluids to stay hydrated.
Correct Answer: A
Rationale: The correct answer is A: Rest frequently throughout the day. This is important for a client with hepatitis B to allow the body to heal and conserve energy. Choice B may be harmful as excessive physical activity can strain the liver. Choice C is incorrect as medication for hepatitis B is usually taken on an empty stomach. Choice D is important but not specific to hepatitis B management.
A nurse is reviewing the laboratory findings for a client who developed fat embolism syndrome (FES) following a fracture. Which of the following laboratory findings should the nurse expect?
- A. Increased serum calcium level
- B. Decreased serum calcium level
- C. Increased white blood cell count
- D. Decreased platelet count
Correct Answer: B
Rationale: The correct answer is B: Decreased serum calcium level. In fat embolism syndrome (FES), fat globules enter the bloodstream, leading to blockages in small blood vessels. This can cause a decrease in serum calcium due to the formation of fat emboli in the pulmonary circulation, leading to hypoxia and subsequent release of inflammatory mediators that can affect calcium levels. The other choices are incorrect because in FES, there is no direct effect on serum calcium levels. Increased serum calcium levels (choice A) are not expected in FES. While increased white blood cell count (choice C) and decreased platelet count (choice D) can occur in response to inflammation or infection associated with FES, they are not specific laboratory findings for FES.
A nurse is teaching a client about the causes of osteoporosis. The nurse should include which of the following types of medication therapy as a risk factor for osteoporosis?
- A. Thyroid hormones
- B. Antihypertensives
- C. Steroids
- D. Insulin
Correct Answer: C
Rationale: The correct answer is C: Steroids. Steroids, specifically glucocorticoids, are known to increase the risk of osteoporosis by decreasing bone formation and increasing bone resorption. Long-term use of steroids can lead to bone loss, making individuals more susceptible to fractures. Thyroid hormones (A) do not directly cause osteoporosis. Antihypertensives (B) and insulin (D) are not associated with increased risk of osteoporosis.
A nurse in an ophthalmology clinic assesses a client suspected of having cataracts. What is an expected symptom?
- A. Eye pain
- B. Sudden vision loss
- C. Decreased ability to perceive colors
- D. Excessive tearing
Correct Answer: C
Rationale: The correct answer is C: Decreased ability to perceive colors. Cataracts cause clouding of the eye's lens, leading to a decrease in the perception of colors. Eye pain (A) is not a typical symptom of cataracts. Sudden vision loss (B) is more commonly associated with conditions like retinal detachment. Excessive tearing (D) is not a prominent symptom of cataracts. Make sure to assess for other symptoms like blurred vision, sensitivity to light, and difficulty seeing at night.
A nurse is providing discharge teaching to a client who has asthma and new prescriptions for cromolyn and albuterol, both by nebulizer. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will be sure to take the albuterol before taking the cromolyn.
- B. I will take both medications at the same time.
- C. I will take the cromolyn before taking albuterol.
- D. I will take the medications in any order.
Correct Answer: A
Rationale: The correct answer is A: "I will be sure to take the albuterol before taking the cromolyn." This is because albuterol is a bronchodilator that helps to open up the airways quickly, providing immediate relief during an asthma attack. Cromolyn, on the other hand, is a mast cell stabilizer that helps to prevent asthma attacks but does not provide immediate relief. Taking albuterol first allows for quick relief, followed by cromolyn for long-term prevention.
Choice B is incorrect as taking both medications at the same time may not allow for the full effectiveness of each drug. Choice C is incorrect as cromolyn should be taken before albuterol to allow time for it to take effect. Choice D is incorrect as there is a specific order in which these medications should be taken for optimal results.