Nokea
In a 24 hour urine specimen started Friday, 9:00 A.M, which of the following if done by a Nurse indicate a NEED for further procedural debriefing?
- A. The nurse ask the client to urinate at 9:00 A.M, Friday and she included the urine in the 24 hour urine specimen
- B. The nurse discards the Friday 9:00 A M urine of the client
- C. The nurse included the Saturday 9:00 A.M urine of the client to the specimen collection
- D. The nurse added preservatives as per protocol and refrigerates the specimen
Correct Answer: A
Rationale: Including 9:00 AM Friday urine e.g., pre-start skew 24-hour totals (9 AM Friday to 9 AM Saturday); it's discarded. Discarding start, including end, and preserving are correct. Nurses need debriefing here e.g., timing for accurate collection, per lab standards.
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Which of the following clinical findings is expected in a patient who has undergone gastric lavage and prolonged vomiting?
- A. Decreased serum pH
- B. Increased serum bicarbonate level
- C. Increased serum oxygen level
- D. Decreased serum osmotic level
Correct Answer: A
Rationale: Prolonged vomiting and gastric lavage lose stomach acid (HCl), causing metabolic alkalosis elevated pH, not decreased (acidosis). Bicarbonate rises as the body compensates, not oxygen or osmolarity, which are unrelated. Nurses monitor for alkalosis symptoms (e.g., tetany), correcting with fluids like saline, restoring acid-base balance disrupted by gastric content loss.
A client with hypertension is being taught about the DASH diet. Which of the following statements by the client indicates an understanding of the teaching?
- A. I should increase my intake of sodium-rich foods.
- B. I should decrease my intake of potassium-rich foods.
- C. I should increase my intake of fruits and vegetables.
- D. I should decrease my intake of whole grains.
Correct Answer: C
Rationale: The correct answer is C. The Dietary Approaches to Stop Hypertension (DASH) diet is recommended for managing hypertension. Increasing the intake of fruits and vegetables is a key component of the DASH diet as these foods are rich in nutrients that can help lower blood pressure levels. Choices A, B, and D are incorrect because they go against the principles of the DASH diet, which focuses on reducing sodium intake, increasing potassium-rich foods, and consuming whole grains.
Which of the following nursing intervention would least likely be effective when dealing with a client with aggressive behavior?
- A. Approach him in a calm manner
- B. Provide opportunities to express feelings
- C. Maintain eye contact with the client
- D. Isolate the client from others
Correct Answer: C
Rationale: Maintaining eye contact (C) is least effective with aggressive clients; it can escalate tension, per de-escalation guidelines. Calm approach (A), expression (B), and isolation (D) soothe or manage behavior. Eye contact may provoke, making C incorrect.
The nurse ensured Mr. Gary's treatment wishes were followed. This is an example of?
- A. Advocacy
- B. Management
- C. Health literacy
- D. Quality improvement
Correct Answer: A
Rationale: Ensuring treatment wishes is advocacy (A) protecting rights, per definition. Management (B) organizes, literacy (C) understands, QI (D) enhances not rights-specific. A fits patient voice, making it correct.
The nurse is providing care for a client with a chest tube. If the chest tube becomes disconnected from the drainage system, the nurse should:
- A. Secure the chest tube with tape and notify the physician
- B. Clamp the chest tube near the insertion site
- C. Submerge the end of the tube in sterile water
- D. Insert the tube into the drainage system without cleansing
Correct Answer: C
Rationale: Submerging the chest tube end in sterile water creates a water seal, preventing pneumothorax if disconnected taping delays, clamping risks tension pneumothorax, and reinserting uncleaned spreads infection. Nurses act quickly, ensuring lung re-expansion, critical in chest tube care.