Nokea
The healthcare provider is caring for a client who is experiencing fluid volume deficit (dehydration). Which intervention should the healthcare provider implement to assess the effectiveness of fluid replacement therapy?
- A. Monitor daily weights
- B. Assess skin turgor
- C. Evaluate blood pressure trends
- D. Check urine specific gravity
Correct Answer: A
Rationale: Monitoring daily weights is an accurate method to assess the effectiveness of fluid replacement therapy because changes in weight reflect changes in fluid balance. Fluid volume deficit can be objectively evaluated by monitoring daily weights as it provides a more precise measurement of fluid status over time.
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When is the first dose of Hepatitis B given?
- A. In the hospital at birth
- B. At one year old
- C. At six months
- D. At 18 months
Correct Answer: A
Rationale: The first dose of the Hepatitis B vaccine is usually administered at birth in the hospital to provide early protection against the virus. Giving the vaccine at birth helps prevent perinatal transmission of Hepatitis B from an infected mother to her newborn. Therefore, it is important to administer the first dose as soon as possible after birth to ensure the best protection.
The healthcare provider assesses a 2-year-old who is admitted for dehydration and finds that the peripheral IV rate by gravity has slowed, even though the venous access site is healthy. What should the healthcare provider do next?
- A. Apply a warm compress proximal to the site.
- B. Check for kinks in the tubing and raise the IV pole.
- C. Adjust the tape that stabilizes the needle.
- D. Flush with normal saline and recount the drop rate.
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
When assisting a client with right-sided hemiplegia to get into a wheelchair, how should the nurse position the wheelchair?
- A. On the left side of the bed facing the foot of the bed.
- B. On the right side of the bed facing the head of the bed.
- C. Perpendicular to the bed on the right side.
- D. Facing the bed on the left side of the bed.
Correct Answer: A
Rationale: Positioning the wheelchair on the left side of the bed facing the foot of the bed is the correct approach when assisting a client with right-sided hemiplegia. Placing the wheelchair on the left side allows the client to stand on their unaffected foot and pivot to sit down safely. This positioning facilitates a smoother transfer and helps maintain the client's stability during the process.
A female client with chronic back pain has been taking muscle relaxants and analgesics to manage the discomfort, but is now experiencing an acute episode of pain that is not relieved by this medication regimen. The client tells the nurse that she does not want to have back surgery for a herniated intervertebral disk, and reports that she has found acupuncture effective in resolving past acute episodes. Which response is best for the nurse to provide?
- A. Surgery removes the disk and is the only treatment that can totally resolve the pain
- B. The medication regimen you previously used should be re-evaluated for dose adjustment
- C. Massage and hot pack treatments are less invasive and can provide temporary relief
- D. Acupuncture is a complementary therapy that is often effective for management of pain
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The healthcare provider is assessing the nutritional status of several clients. Which client has the greatest nutritional need for additional intake of protein?
- A. A college-age track runner with a sprained ankle.
- B. A lactating woman nursing her 3-day-old infant.
- C. A school-aged child with Type 2 diabetes.
- D. An elderly man being treated for a peptic ulcer.
Correct Answer: B
Rationale: A lactating woman (B) has the greatest need for additional protein intake. Lactation increases the metabolic demands for protein to support milk production, making it essential for the mother to have a higher protein intake. While clients in choices A, C, and D also require protein for various reasons, they do not have the same increased protein demands as a lactating woman.