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In the intensive care unit, the nurse cares for a client admitted with a head injury who develops syndrome of inappropriate antidiuretic hormone. Which data should the nurse expect with the onset of this condition? Select all that apply.
- A. Decreased serum osmolality
- B. High serum osmolality
- C. High urine specific gravity
- D. Increased urine output
- E. Low serum sodium
Correct Answer: A,C,E
Rationale: SIADH causes water retention, leading to decreased serum osmolality , high urine specific gravity , and low serum sodium due to dilution. High osmolality and increased urine output are opposite findings.
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A client indicates to the nurse a desire to become pregnant. The client drinks 1-2 glasses of wine on weekends. BMI is 32 kg/m². Which teachings should the nurse reinforce as part of proper preconception health care for this client? Select all that apply.
- A. Avoid eating undercooked hamburgers
- B. Do not have more than 1 alcoholic drink per week
- C. Maintain current BMI
- D. Receive a rubella vaccine at least 3 months before attempting pregnancy
- E. Take 0.4 mg folic acid supplementation daily
Correct Answer: A,B,D,E
Rationale: To optimize preconception health: Avoid undercooked meat to prevent toxoplasmosis; limit alcohol to minimal or none to avoid fetal alcohol syndrome; rubella vaccine prevents congenital rubella syndrome; and folic acid reduces neural tube defects. A BMI of 32 is obese and should be reduced for healthier pregnancy outcomes.
A nurse from the float pool is giving medications on a pediatric unit and is to give medications to a 2-year-old child in room 534, bed B. The child in that room does not have an identification band. What is the best action for the nurse to take?
- A. Ask the child what his name is
- B. Give the medication to the child in room 534, bed B
- C. Refuse to give the medication
- D. Ask the adults beside the bed the name of the child in that bed
Correct Answer: C
Rationale: Refusing to give medication without proper identification ensures safety, as a 2-year-old cannot reliably confirm identity.
The nurse is preparing to give a heparin injection to a client who is severely malnourished and has minimal adipose tissue. Which method of injection would be appropriate for this client?
- A. EX12_Q49_1.PNG
- B. EX12_Q49_2.PNG
- C. EX12_Q49_3.PNG
- D. EX12_Q49_4.PNG
Correct Answer: C
Rationale: For a malnourished client with minimal adipose tissue, heparin should be injected at a 90-degree angle using a 25-gauge needle to ensure subcutaneous delivery without hitting muscle.
A client is receiving oxygen therapy via a nasal cannula. When providing nursing care, which of the following interventions would be appropriate?
- A. Determine that adequate mist is supplied
- B. Inspect the nares and ears for skin breakdown
- C. Lubricate the tips of the cannula before insertion
- D. Maintain sterile technique when handling cannula
Correct Answer: B
Rationale: Inspect the nares and ears for skin breakdown. Oxygen therapy can cause drying of the nasal mucosa. Pressure from the tubing can cause skin irritation.
The physician has recommended that the client increase the amount of dietary iron. The nurse knows that the client understands the recommendation when the client selects which foods?
- A. Orange juice, scrambled eggs, and toast
- B. Hot dog and roll, French fries, and cola
- C. Roast beef, carrots, and rice
- D. Baked chicken, peas, and noodles
Correct Answer: C
Rationale: Roast beef is high in iron, suitable for increasing dietary iron. Other options lack significant iron sources.