Nokea
On the third post-burn day, the nurse finds that the client's hourly urine output is 26 ml. The nurse should continue to assess the client and notify the doctor for an order to:
- A. Decrease the rate of the intravenous infusion.
- B. Change the type of intravenous fluid being administered.
- C. Change the urinary catheter.
- D. Increase the rate of the intravenous infusion.
Correct Answer: D
Rationale: The urinary output should be maintained between 30 ml and 50 ml per hour. The first action should be to increase the IV rate to prevent increased acidosis. Answer A would lead to diminished output, so it is incorrect. There is no indication that the type of IV fluid is not appropriate as is suggested by answer B, making it incorrect. Answer C would not increase the client's output and would place the client at greater risk for infection, so it is incorrect.
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An adult client who had major abdominal surgery is returned to her room on the surgical nursing unit. The postanesthesia nurse reports that the client is awake and has stable vital signs. She has a nasogastric tube in place that is attached to intermittent suction. How should the nurse position the client?
- A. Supine
- B. Semi-sitting
- C. Dorsal recumbent
- D. Prone
Correct Answer: B
Rationale: Semi-sitting facilitates breathing, reduces aspiration risk with a nasogastric tube, and promotes comfort post-abdominal surgery. Supine or dorsal recumbent increases aspiration risk, and prone is contraindicated.
The nurse is caring for a client who is postoperative day 1 after a total hip replacement. Which of the following actions is the PRIORITY?
- A. Encourage the client to use the incentive spirometer.
- B. Administer pain medication as needed.
- C. Position the client with the legs abducted.
- D. Check the surgical dressing for drainage.
Correct Answer: C
Rationale: Positioning with legs abducted prevents hip dislocation, a critical complication post-hip replacement. Options A, B, and D are important but secondary: incentive spirometry prevents pneumonia, pain management supports recovery, and dressing checks monitor bleeding.
A 28-year-old primigravida with pregestational diabetes visits the clinic 6 weeks gestation. Which of the following statements indicates that she understands the nurse's teaching regarding her insulin needs during pregnancy?
- A. As the baby grows, I will need more insulin because the baby will not be able to make insulin.
- B. Changes in hormone levels will make my body more resistant to insulin, so I will need more insulin as the pregnancy progresses.
- C. As the baby grows, I will need less insulin because the baby uses up any extra glucose.
- D. If I maintain an adequate balance of diet and exercise, my insulin requirements will be the same.
Correct Answer: B
Rationale: Pregnancy hormones increase insulin resistance, requiring more insulin as pregnancy progresses in diabetic patients. Other statements are incorrect regarding insulin dynamics.
The nurse knows that the MOST reliable client measure for evaluating the desired response diuretic therapy is to
- A. obtain daily weights.
- B. obtain urinalysis.
- C. monitor Na⺠and K⺠levels.
- D. measure intake.
Correct Answer: A
Rationale: effectiveness of diuretic therapy is demonstrated by decreased edema and is measured by daily weights
The nurse admits a client newly diagnosed with hypertension. What is the best method for assessing the blood pressure?
- A. Standing and sitting
- B. In both arms
- C. After exercising
- D. Supine position
Correct Answer: B
Rationale: In both arms. This ensures accuracy, as stenosis in one subclavian artery could cause a false reading.