Nokea
The client's blood urea nitrogen (BUN) concentration is elevated in acute renal failure. What is the likely cause of this finding?
- A. Fluid retention.
- B. Hemolysis of red blood cells.
- C. Below-normal metabolic rate.
- D. Reduced renal blood flow.
Correct Answer: D
Rationale: Reduced renal blood flow impairs urea excretion, causing elevated BUN levels in acute renal failure.
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The nurse is caring for a client who sustained injuries from a light bulb explosion. On assessment, the nurse notes that a piece of glass was lodged in the client's eye. The initial nursing intervention should be which of the following?
- A. Attempt to carefully remove the glass from the eye
- B. Reassure the client that everything is okay
- C. Administer a sedative for pain relief
- D. Advise the client to remain in a sitting position until a specialist arrives
Correct Answer: D
Rationale: A foreign object like glass in the eye requires specialist intervention. Keeping the client in a sitting position minimizes further damage until a specialist evaluates. Attempting removal, false reassurance, or sedation without specialist input is inappropriate.
A client who has had an above-the-knee amputation is to have a dressing change 45 minutes after arriving in the postanesthesia recovery unit. The nurse should:
- A. Elevate the stump.
- B. Reinforce the dressing.
- C. Call the surgeon.
- D. Draw a mark around the site.
Correct Answer: C
Rationale: Excessive bleeding requires the surgeon's evaluation to prevent complications.
A client with a history of systemic lupus erythematosus was admitted with a severe viral respiratory tract infection and diffuse petechiae. Based on these data, it is most important that the nurse further evaluate the client's recent:
- A. Quality and quantity of food intake.
- B. Type and amount of fluid intake.
- C. Weakness, fatigue, and ability to get around.
- D. Length and amount of menstrual flow.
Correct Answer: D
Rationale: Systemic lupus erythematosus (SLE) can cause thrombocytopenia, and diffuse petechiae suggest a low platelet count. Heavy menstrual bleeding is a common manifestation of thrombocytopenia in women and should be evaluated to assess the extent of bleeding and guide treatment. Food, fluid intake, and fatigue are less directly related to the petechiae.
Prior to being transported to the surgery suite, the nurse asks the client whether he has any allergies. The client responds, 'Doesn't anyone communicate with anyone? I have been asked that question over and over!' What is the nurse's best response?
- A. œI'm sorry! I just have to ask that question for the record.'
- B. œIt's an important question and we just have to check.'
- C. œYou will hear it again and again as you go through surgery.'
- D. œThis question is asked for verification and safety with each new phase of treatment.'
Correct Answer: D
Rationale: Explaining that repeated allergy checks are for safety and verification reassures the client while clarifying the purpose of the question. This response addresses the client's frustration and emphasizes the importance of the process.
A 34-year-old female is diagnosed with hypothyroidism. The nurse should assess the client for which of the following? Select all that apply.
- A. Rapid pulse.
- B. Decreased energy and fatigue.
- C. Weight gain of 10 lb.
- D. Fine, thin hair with hair loss.
- E. Constipation.
- F. Menorrhagia.
Correct Answer: B,C,D,E,F
Rationale: Hypothyroidism slows metabolism, leading to decreased energy, fatigue, weight gain, hair loss, constipation, and heavy menstrual periods (menorrhagia). Rapid pulse is associated with hyperthyroidism, not hypothyroidism.