Nokea
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.
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Which is an appropriate outcome for the nursing diagnosis of Body Image Disturbance for a client with anorexia nervosa?
- A. The client verbalizes knowledge of a maintenance diet.
- B. The client demonstrates assertiveness with family.
- C. The client verbalizes her body size accurately.
- D. The client demonstrates control of obsessive behaviors.
Correct Answer: C
Rationale: Part of the problem for anorexic clients is an altered view of their body appearance (visualizing themselves as fat even when they are emaciated). Knowledge of a maintenance diet involves a knowledge deficit. Assertiveness with family involves possible resolution of family-dynamic issues. Control of obsessive behaviors involves psychological adaptation.
At what point in the nurse-client relationship should termination first be addressed?
- A. in the working phase
- B. in the termination phase
- C. in the orientation phase
- D. when the client initially brings up the topic
Correct Answer: C
Rationale: The client has a right to know the parameters of the nurse-client relationship. If the relationship is to be time limited, the client should be informed of the number of sessions. If it is open-ended, the termination date is not known at the outset, and the client should know that this is an issue that is negotiated at a later date.
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 immobile client is in a hospital bed at home. Which information should the home health nurse include when teaching family caregivers how to safely move and reposition the client?
- A. Before moving the client, raise the bed to waist level. After completing the move, return the bed to the lowest level.
- B. The pillow should be removed from under the client's head when positioning in a dorsal recumbent position.
- C. Tighten your abdominal muscles and keep your feet together; use a lift sheet and pull the client up in bed.
- D. When the client is lying on the back, rest the client's heels on the bed and keep the feet perpendicular to the legs.
Correct Answer: A
Rationale: A: Raising the bed to waist level and lowering it after reduces injury risk. B: A pillow prevents neck hyperextension. C: A broad stance, not feet together, improves balance. D: Heels should be off the bed to prevent pressure ulcers.
The client is in skeletal traction with 20 lb of traction applied to a right lower leg fracture. Which intervention should the nurse perform at regular intervals?
- A. Perform pin site care
- B. Remove the weights
- C. Reposition the right leg
- D. Perform passive ROM to the legs
Correct Answer: A
Rationale: A: Regular pin site care prevents infection. B: Weights are only removed in emergencies. C: Repositioning disrupts alignment. D: ROM is avoided to maintain traction.