Nokea
An adult client has been placed on a fluid restriction of 1200 mL per day. The nurse discusses the fluid restriction with the dietitian and then plans to allow the client to have how many milliliters of fluid from 7:00 am to 3:00 pm?
- A. 400 mL
- B. 600 mL
- C. 800 mL
- D. 1000 mL
Correct Answer: B
Rationale: When a client is on fluid restriction, the nurse informs the dietary department and discusses the allotment of fluid per shift with the dietitian. When calculating how to distribute a fluid restriction, the nurse usually allows half of the daily allotment (600 mL) during the day shift, when the client eats two meals and takes most medications. Another two-fifths (480 mL) is allotted to the evening shift, with the balance (120 mL) allowed during the nighttime.
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Place these steps of the medication reconciliation process in the correct sequential order from # 1 to # 5. Do NOT include steps that are not part of the medication reconciliation process. 1: Compile a list of newly prescribed medications and other preparations 2: Compile a list of current medications and other preparations 3: Compile a list of only current vitamins, over the counter medications, herbal remedies, nutritional and dietary supplements 4: Compare the two lists and make note of any discrepancies and inconsistencies 5: Employ critical thinking and professional judgments during the comparisons of the two lists 6: Communicate and document the new list of medications to the appropriate healthcare providers
- A. 3,2,1,4,6
- B. 2,1,4,5,6
- C. 1,2,3,5,4
- D. 4,1,3,2,6
Correct Answer: B
Rationale: The medication reconciliation process involves: 1) Compiling current medications, 2) Compiling new medications, 3) Comparing lists for discrepancies, 4) Using critical thinking, 5) Communicating the reconciled list.
The nurse is caring for a client with a suspected anaphylactic reaction. Which assessment finding confirms this diagnosis?
- A. Wheezing and hypotension
- B. Fever and rash
- C. Bradycardia and hypertension
- D. Nausea and diarrhea
Correct Answer: A
Rationale: Wheezing and hypotension are hallmark signs of anaphylaxis, indicating airway constriction and systemic vasodilation requiring immediate intervention.
A client has a cerclage placed at 16 weeks' gestation. She has had no contractions and her cervix is dilated 2 cm. The nurse is preparing the client for discharge. Which statement by the client should indicate to the nurse that the client needs further instruction?
- A. I will need more frequent prenatal visits.'
- B. I should call if I am leaking fluid or have bleeding or contractions.'
- C. I can have sex again in about 2 weeks.'
- D. I can have nothing in my vagina until I am at term.'
Correct Answer: C
Rationale: Sexual intercourse is typically contraindicated after cerclage until term to prevent complications. The other statements reflect correct understanding of cerclage care.
The nurse is preparing to administer a blood transfusion. Which solution should be used to prime the tubing?
- A. Dextrose 5% in water.
- B. Lactated Ringer's.
- C. 0.9% sodium chloride.
- D. Heparinized saline.
Correct Answer: C
Rationale: 0.9% sodium chloride is compatible with blood products and used to prime tubing to prevent hemolysis.
A nurse is counseling a mother with young children after the mother left her abusive husband 6 months ago. The mother says, 'My 6-year-old, Kevin, is starting to act just like his father. I just don't know how to handle this.' Which response by the nurse is most appropriate?
- A. You'll have to limit Kevin's contact with his father.'
- B. Counseling for Kevin would be helpful.'
- C. Most boys outgrow these behaviors.'
- D. Setting limits on his behavior is all you need to do now.'
Correct Answer: B
Rationale: Counseling can help address behavioral issues potentially stemming from trauma or modeling, providing professional support for the child.