Nokea
An elderly client is admitted to the unit with a temperature of $100.2^{\circ}$, urinary specific gravity of 1.032, and a dry tongue. The nurse should anticipate an order for:
- A. An antibiotic
- B. An analgesic
- C. A diuretic
- D. An IV of normal saline
Correct Answer: D
Rationale: The symptoms (fever, high urinary specific gravity, dry tongue) indicate dehydration. IV normal saline is the priority to rehydrate. Antibiotics require infection confirmation, analgesics address pain, and diuretics worsen dehydration.
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A client returned from surgery for a perforated appendix with localized peritonitis. In view of this diagnosis, how would the nurse position the client?
- A. Prone
- B. Dorsal recumbent
- C. Semi-Fowler
- D. Supine
Correct Answer: C
Rationale: Semi-Fowler. The semi-Fowler position assists drainage and prevents spread of infection throughout the abdominal cavity.
The nurse is caring for a client who is postoperative day 1 after a lumbar laminectomy. Which of the following actions should the nurse prioritize?
- A. Encourage log-rolling when repositioning
- B. Administer pain medication as needed
- C. Keep the head of the bed elevated 45 degrees
- D. Monitor the surgical drain for output
Correct Answer: A
Rationale: Log-rolling maintains spinal alignment, preventing complications post-laminectomy. Options B, C, and D are secondary: pain management is routine, 45-degree elevation is excessive, and drain monitoring is less urgent.
Which of the following snacks would be suitable for a child with gluten-induced enteropathy?
- A. A soft oatmeal cookie
- B. Buttered popcorn
- C. A peanut butter and jelly sandwich
- D. Cheese pizza
Correct Answer: B
Rationale: Buttered popcorn is gluten-free, making it suitable for a child with celiac disease (gluten-induced enteropathy). The other options contain gluten.
The nurse is caring for a client with a history of deep vein thrombosis who is receiving warfarin (Coumadin) 5 mg PO daily. Which of the following laboratory results would be of GREATest concern to the nurse?
- A. INR of 3.5.
- B. PTT of 40 seconds.
- C. Platelet count of 200,000/mm^3.
- D. Hemoglobin of 13 g/dL.
Correct Answer: A
Rationale: An INR of 3.5 is above the therapeutic range (2.0–3.0) for DVT, increasing bleeding risk, requiring dose adjustment. Options B, C, and D are normal: PTT is unaffected, platelet count 200,000/mm^3 is adequate, and hemoglobin 13 g/dL is normal.
The nurse is teaching a client with a new diagnosis of epilepsy about phenytoin (Dilantin). Which of the following statements by the client indicates a need for further teaching?
- A. I should brush my teeth regularly.
- B. I should report any skin rashes to my doctor.
- C. I should avoid drinking grapefruit juice.
- D. I should stop this medication if my seizures stop.
Correct Answer: D
Rationale: Stopping phenytoin when seizures stop is incorrect, as epilepsy often requires lifelong treatment to prevent recurrence. Options A, B, and C are correct: oral hygiene prevents gingival hyperplasia, rashes may indicate hypersensitivity, and grapefruit juice does not significantly affect phenytoin.