Nokea
The 24-hour day-night cycle is known as:
- A. circadian rhythm
- B. infradian rhythm
- C. ultradian rhythm
- D. non-REM rhythm
Correct Answer: A
Rationale: The circadian rhythm governs the 24-hour cycle of physiological processes. Infradian rhythms are longer than 24 hours (e.g., menstrual cycle), ultradian rhythms are shorter (e.g., sleep cycles), and non-REM rhythm is not a recognized term.
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A nurse is assessing a patient in the ICU. The patient has the following signs: weak pulse, quick respiration, acetone breath, and nausea. Which of the following conditions is most likely occurring?
- A. Hypoglycemic patient
- B. Hyperglycemic patient
- C. Cardiac arrest
- D. End-stage renal failure
Correct Answer: B
Rationale: All of the clinical signs indicate a hyperglycemic condition.
The nurse is caring for a patient who is hard-of-hearing. Which of the following steps may be appropriate when communicating with the patient?
- A. Divide the verbal communication into smaller sections and address one at a time.
- B. Communicate only with written information.
- C. Ask multiple questions in a row quickly to make sure the client is remaining engaged.
- D. Frequently communicate without assistive devices to help the client improve their hearing.
Correct Answer: A
Rationale: For a client who is hard-of-hearing, verbal communication should be kept concise. If assistive devices are available, they should be used.
The client with diarrhea has had four bowel movements in the past eight hours, measuring 150 mL, 100 mL, 100 mL and 150 mL. The client is to receive one-to-one replacement with a bolus of IV 0.9% NaCl to be infused over the next two hours. How many mL of 0.9% NaCl will the nurse infuse each hour?
Correct Answer: 250
Rationale: Total loss is 500 mL (150+100+100+150). One-to-one replacement means 500 mL over 2 hours, so 500/ 2 = 250 mL per hour.
In evaluating the lab work of a client in a hepatic coma, which of the following lab tests is most important?
- A. Blood urea nitrogen
- B. Serum calcium
- C. Serum ammonia
- D. Serum creatinine
Correct Answer: C
Rationale: Elevated serum ammonia is critical in hepatic coma, as liver failure impairs ammonia metabolism, causing brain-tissue irritation.
The nurse is assessing the female client who is 65 inches tall and has a small body frame. Based on the information in the chart illustrated, what is the client's approximate ideal body weight?
Correct Answer: 117
Rationale: Height is 5'5†(65/ 12 = 5 remainder 5). Formula: 105 lb for 5 ft + 5 lb × 5 = 130 lb. Small frame subtracts 10% (130 × 0.1 = 13 lb). 130 − 13 = 117 lb.