Nokea
A nurse plans care for an older adult who is admitted to the hospital for pneumonia. The client has no known drug allergic status nor a significant medical history. Which action should the nurse include in this clients plan of care?
- A. Initiate Airborne Precautions.
- B. Offer fluids every hour or two.
- C. Administer broad-spectrum antibiotics.
- D. Palpate the clients thyroid gland.
Correct Answer: B
Rationale: Decreased antidiuretic hormone (ADH) production is a normal age-related change, leading to increased urine output and risk of dehydration. Offering fluids regularly helps prevent dehydration in older adults.
You may also like to solve these questions
A nurse cares for a client who has excessive catecholamine release. Which assessment finding should the nurse correlate with this condition?
- A. Decreased blood pressure
- B. Increased pulse
- C. Decreased respiratory rate
- D. Increased urine output
Correct Answer: B
Rationale: Catecholamines activate the sympathetic nervous system, leading to tachycardia (increased pulse) as part of the fight-or-flight response.
A nurse cares for a client who is prescribed a drug that blocks a hormones receptor site. Which therapeutic effects about the nurse expect?
- A. Greater hormone metabolism
- B. Decreased hormone activity
- C. Increased hormone activity
- D. Unchanged hormone response
Correct Answer: B
Rationale: Hormones cause activity in the target tissues by binding with their specific cellular receptor sites, thereby changing the activity of the cell. When receptor sites are occupied by other substances that block hormone binding, the cells response is the same as when the level of the hormone is decreased.
A nurse cares for a client with a deficiency of aldosterone. Which assessment finding should the nurse correlates with this deficiency?
- A. Increased urine output
- B. Vasoconstriction
- C. Blood glucose of 90 mg/L
- D. Normal sodium levels
Correct Answer: A
Rationale: Aldosterone, the major mineralocorticoid, maintains extracellular fluid volume. It promotes sodium and water reabsorption and potassium excretion in the kidney tubules. A client with an aldosterone deficiency will have increased urine output due to decreased reabsorption of sodium and water.
A nurse assesses clients who have endocrine disorders. Which assessment findings are paired correctly with the endocrine disorder? (Select all that apply.)
- A. Thyroid-stimulating hormone: Increase bone formation
- B. Melanocyte-stimulating hormone: Increase bone formation
- C. Parathyroid hormone: Synthesis and release of corticosteroids
- D. Antidiuretic hormone: Increase urinary output
- E. Parathyroid hormone: Increase bone resorption
Correct Answer: A,E
Rationale: Thyroid-stimulating hormone promotes bone formation, and parathyroid hormone increases bone resorption. Melanocyte-stimulating hormone affects pigmentation, not bone formation. Antidiuretic hormone decreases urinary output, and parathyroid hormone does not directly stimulate corticosteroid release.
A nurse collaborates with an unlicensed assistive personnel (UAP) to provide care for a client who is prescribed a 24-hour urine specimen collection. Which statement should the nurse include when delegating this activity to the UAP?
- A. Void the clients first void and collect urine for 24 hours.
- B. Add the preservative to the container at the end of the test.
- C. Start the collection by saving the first urine of the morning.
- D. Ensure the client drinks plenty of water during collection.
Correct Answer: A
Rationale: The 24-hour urine collection begins after discarding the first void to ensure a full 24-hour period of collection. This ensures accurate measurement of excreted substances.