Nokea
The client is admitted with a diagnosis of acute glomerulonephritis. Which assessment finding is most expected?
- A. Hematuria
- B. Hypotension
- C. Weight loss
- D. Clear urine
Correct Answer: A
Rationale: Hematuria is a hallmark of acute glomerulonephritis due to glomerular inflammation and damage, leading to blood in the urine. Hypertension, weight gain, and oliguria are more common than hypotension, weight loss, or clear urine.
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In evaluating the effectiveness of magnesium sulfate (MgSO4), which of the following might indicate that the client was developing MgSO4 toxicity?
- A. A 3+ patellar tendon reflex
- B. Respirations of 12 breaths/min
- C. Urine output of 40 mL/hr
- D. A 2+ proteinuria value
Correct Answer: B
Rationale: MgSO4 is a central nervous system (CNS) depressant. It also relaxes smooth muscle. If the respiratory rate is <16 bpm magnesium toxicity may be developing.
A client is admitted with disseminated herpes zoster (shingles). According to the Centers for Disease Control Guidelines for Infection Control:
- A. Airborne precautions will be needed.
- B. No special precautions will be needed.
- C. Only contact precautions will be needed.
- D. Droplet precautions will be needed.
Correct Answer: A
Rationale: Disseminated herpes zoster requires airborne precautions because the varicella-zoster virus can spread through respiratory droplets in immunocompromised patients.
A client with a history of Crohn's disease is admitted with a small bowel obstruction. The nurse should give priority to:
- A. Monitoring for dehydration
- B. Administering pain medication
- C. Preparing for surgery
- D. Providing nutritional supplements
Correct Answer: A
Rationale: Small bowel obstruction in Crohn's disease can cause fluid loss through vomiting or sequestration, making monitoring for dehydration the priority to prevent hypovolemia.
A client is being discharged and will continue enteral feedings at home. Which of the following statements by a family member indicates the need for further teaching?
- A. If he develops diarrhea lasting for more than 2-3 days, I will contact the doctor or nurse.
- B. I should anticipate that he will gain about 1 lb/day now that he is on continuous feedings.
- C. It is important to keep the head of his bed elevated or sit him in the chair during feedings.
- D. I should use prepared or open formula within 24 hours and store unused portions in the refrigerator.
Correct Answer: B
Rationale: Diarrhea is a complication of tube feedings that can lead to dehydration. Diarrhea may be the result of hypertonic formulas that can draw fluid into the bowel. Other causes of diarrhea may be bacterial contamination, fecal impaction, medications, and low albumin. A consistent weight gain of more than 0.22 kg/day (1/2 lb/day) over several days should be reported promptly. The client should be evaluated for fluid volume excess. Elevating the client's head prevents reflux and thus formula from entering the airway. Bacteria proliferate rapidly in enteral formulas and can cause gastroenteritis and even sepsis.
A client returns for her 6-month prenatal checkup and has gained 10 lb in 2 months. The results of her physical examination are normal. How does the nurse interpret the effectiveness of the instruction about diet and weight control?
- A. She is compliant with her diet as previously taught.
- B. She needs further instruction and reinforcement.
- C. She needs to increase her caloric intake.
- D. She needs to be placed on a restrictive diet immediately.
Correct Answer: B
Rationale: She is probably not compliant with her diet and exercise program. Recommended weight gain during second and third trimesters is approximately 12 lb. Because of her excessive weight gain of 10 lb in 2 months, she needs re-evaluation of her eating habits and reinforcement of proper dietary habits for pregnancy. A 2200-calorie diet is recommended for most pregnant women with a weight gain of 27-30 lb over the 9-month period. With rapid and excessive weight gain, PIH should also be suspected. She does not need to increase her caloric intake, but she does need to re-evaluate dietary habits. Ten pounds in 2 months is excessive weight gain during pregnancy, and health teaching is warranted. Restrictive dieting is not recommended during pregnancy.