Nokea
A patient is admitted for hypovolemia associated with multiple draining wounds. Which assessment would be the most accurate way for the nurse to evaluate fluid balance?
- A. Skin turgor
- B. Daily weight
- C. Presence of edema
- D. Hourly urine output
Correct Answer: B
Rationale: Daily weight is the most easily obtained and accurate means of assessing volume status. Skin turgor varies considerably with age and can be affected by various factors other than fluid balance. Presence of edema indicates excess fluid has moved into the interstitial space, which may not always be directly correlated with overall fluid balance. Hourly urine outputs, though important, do not provide a comprehensive picture of fluid balance as they do not consider fluid intake, insensible losses, or other sources of fluid loss.
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At 01:00 on a male client's second postoperative night, the client states he is unable to sleep and plans to read until feeling sleepy. What action should the nurse implement?
- A. Leave the room and close the door to the client's room
- B. Assess the appearance of the client's surgical dressing
- C. Bring the client a prescribed PRN sedative-hypnotic
- D. Discuss symptoms of sleep deprivation with the client
Correct Answer: A
Rationale: The client has a plan to read until feeling sleepy, indicating an intention to sleep. Therefore, offering a PRN sedative-hypnotic (C) is unnecessary, especially since it is a stronger sleep aid. Option (D) is not needed as the client already has a plan to address his sleeplessness. Assessing the surgical dressing (B) is not relevant to the client's immediate need for sleep. Leaving the room and closing the door (A) is the appropriate action to provide a conducive environment for the client to rest.
The nurse observes an unlicensed assistive personnel (UAP) who is providing a total bed bath for a confused and lethargic client. The UAP is soaking the client's foot in a basin of warm water placed on the bed. What action should the nurse take?
- A. Remove the basin of water from the client's bed immediately
- B. Remind the UAP to dry between the client's toes completely
- C. Advise the UAP that this procedure is damaging to the skin
- D. Add skin cream to the basin of water while the foot is soaking
Correct Answer: B
Rationale: Choice (B) is the correct action for the nurse to take in this situation. Ensuring that the UAP dries between the client's toes completely is crucial to prevent skin breakdown due to excessive moisture. While keeping the client's feet clean is important, maintaining dryness is paramount for skin integrity. Choices (A), (C), and (D) are incorrect: (A) removing the basin of water immediately may disrupt the care process without addressing the root issue, (C) advising the UAP that the procedure is damaging to the skin is not as immediate or specific to the observed problem, and (D) adding skin cream to the water may not address the need for drying the client's toes thoroughly.
A client who has a body mass index (BMI) of 30 is requesting information on the initial approach to a weight loss plan. Which action should the nurse recommend first?
- A. Plan low-carbohydrate and high-protein meals
- B. Engage in moderate physical activity for an hour daily
- C. Keep a record of food and drinks consumed daily
- D. Participate in a group exercise class 3 times a week
Correct Answer: C
Rationale: A BMI of 30 indicates the patient is obese. The first step in a weight loss plan should be to keep a food journal to track calorie intake, which can help in meal planning and creating a workout routine. Choice (A) suggests a dietary approach, which is important but not the first step. Choice (B) recommends strenuous activity, which may not be suitable for everyone and is not the initial step. Choice (D) involves group exercise, which can be beneficial but is not the primary action to take at the beginning of a weight loss plan.
A child is diagnosed with acquired aplastic anemia. The nurse knows that this child has the best prognosis with which treatment regimen?
- A. blood transfusion
- B. chemotherapy
- C. bone marrow transplantation
- D. immunosuppressive therapy
Correct Answer: C
Rationale: In the case of acquired aplastic anemia, bone marrow transplantation offers the best chance of cure as it replaces the abnormal stem cells with healthy ones. Blood transfusion may provide temporary relief by replacing blood cells, but it does not address the root cause of the condition. Chemotherapy may be used in some cases, but it is not the preferred treatment for acquired aplastic anemia. While immunosuppressive therapy can be effective, especially in patients who are not candidates for a bone marrow transplant, it is not the first-line treatment and does not offer the same potential for a cure as bone marrow transplantation.
A patient receives 3% NaCl solution for correction of hyponatremia. Which assessment is most important for the nurse to monitor while the patient is receiving this infusion?
- A. Lung sounds
- B. Urinary output
- C. Peripheral pulses
- D. Peripheral edema
Correct Answer: A
Rationale: The correct answer is A: Lung sounds. Hypertonic solutions like 3% NaCl can cause water retention, leading to fluid excess. Monitoring lung sounds is crucial as crackles may indicate pulmonary edema, a serious manifestation of fluid excess. While monitoring urinary output, peripheral pulses, and peripheral edema are also important when administering hypertonic solutions, they do not provide immediate clues to acute respiratory or cardiac decompensation like lung sounds.