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For a patient receiving furosemide, the nurse evaluates the medication as being effective if which of the following effects occurs?
- A. Urine output increased
- B. Heart rate increased
- C. Serum potassium decreased
- D. Pulse pressure increased
Correct Answer: A
Rationale: Furosemide is a loop diuretic commonly used to help the body get rid of excess salt and water through increased urine output. By inhibiting the reabsorption of sodium and chloride in the loop of Henle in the kidneys, furosemide promotes the excretion of water, sodium, chloride, and other electrolytes. Therefore, the nurse would evaluate the medication as effective if the patient experiences increased urine output, as it indicates that the furosemide is working to eliminate excess fluids from the body.
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A 52-year old female tells the nurse that she has found a painless lump in her right breast during her monthly self-examination. Which assessment finding would strongly suggest that this client's lump is cancerous?
- A. Eversion of the right nipple and mobile
- B. Mobile mass that is soft and easily mass delineated
- C. Non-mobile mass with irregular edges
- D. Non palpable right axillary lymph nodes
Correct Answer: C
Rationale: A non-mobile mass with irregular edges is a strong indicator of a cancerous lump in the breast. Cancerous lumps often feel fixed or attached to the surrounding tissue and may have irregular shapes rather than smooth, round contours. The lack of mobility and irregular edges increase suspicion for malignancy and warrant further investigation, such as imaging studies and biopsies. It is important for this patient to follow up with a healthcare provider promptly for further evaluation and appropriate management.
Stefan was diagnosed with secondary vesicoureteral reflux; such condition usually results from which of the following?
- A. Acidic urine
- B. Congenital defects
- C. Hydronephrosis
- D. Infection
Correct Answer: D
Rationale: Secondary vesicoureteral reflux is a condition where urine flows backward from the bladder into the ureters and possibly towards the kidneys due to an underlying cause. In the majority of cases, it results from an infection in the urinary tract, particularly in the bladder. The infection leads to inflammation and weakening of the valves that normally prevent urine from refluxing back towards the kidneys. This condition is more common in children but can also occur in adults. Treating the underlying infection is essential to managing secondary vesicoureteral reflux and preventing complications such as kidney damage.
Which of the ff. safety instructions should the nurse give a patient who has temporarily dilated pupils?
- A. Keep eyes closed
- B. Wear sunglasses
- C. Do not drive for 8 hours
- D. Avoid caffeinated beverages
Correct Answer: B
Rationale: Dilated pupils can cause increased sensitivity to light, leading to discomfort or visual disturbances. Wearing sunglasses can help protect the eyes from bright light and reduce potential discomfort for the patient. This safety instruction is important to promote the patient's comfort and prevent any potential harm due to light sensitivity.
Which of the ff nursing interventions is involved when caring for a client with influenza?
- A. Maintaining airborne transmission
- B. Oxygen administration
- C. Immediate recognition of respiratory
- D. Complete bed rest distress
Correct Answer: C
Rationale: When caring for a client with influenza, immediate recognition of respiratory distress is crucial. Influenza can lead to respiratory complications such as pneumonia, which may result in respiratory distress. Early detection of symptoms such as increased respiratory rate, shortness of breath, and chest pain can help in providing prompt intervention and preventing further complications. Therefore, the nursing intervention involved in caring for a client with influenza is to closely monitor the respiratory status and quickly recognize any signs of respiratory distress. This proactive approach can potentially save the client's life and improve outcomes.
Parents of a 3-year-old child with congenital heart disease are afraid to let their child play with other children because of possible overexertion. The nurse's reply should be based on which statement?
- A. The child needs opportunities to play with peers.
- B. The child needs to understand that peers' activities are too strenuous.
- C. Parents can meet all of the child's needs.
- D. Constant parental supervision is needed to avoid overexertion.
Correct Answer: A
Rationale: The nurse's reply should be based on the statement that "the child needs opportunities to play with peers." It is important for children to engage in play and social interactions with their peers for their overall development, including social, emotional, cognitive, and physical growth. By allowing the child with congenital heart disease to play with other children, under appropriate supervision, the child can still have enriching experiences while ensuring their safety and well-being. It is essential to strike a balance between enabling the child to participate in activities and managing any potential risks associated with their condition. A supportive environment that encourages play and socialization with peers can contribute positively to the child's development and quality of life.