Nokea
The nurse administers 2 units of salt-poor albumin to a client with portal hypertension and ascites. The nurse explains to the client that this is administered to:
- A. Provide nutrients
- B. Increase protein stores
- C. Elevate the circulating blood volume
- D. Divert blood flow away from the liver temporarily
Correct Answer: C
Rationale: The correct answer is C: Elevate the circulating blood volume. Salt-poor albumin is given to increase the circulating blood volume, which helps reduce ascites by improving fluid distribution within the body. Choices A, B, and D are incorrect because salt-poor albumin is not administered to provide nutrients, increase protein stores, or divert blood flow away from the liver.
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Which of the following is inappropriate in collecting midstream clean-catch urine specimen for urine analysis?
- A. Collect early in the morning, first voided specimen
- B. Do perineal care before specimen collection
- C. Collect 5 to 10 ml of urine
- D. Discard the first flow of urine
Correct Answer: C
Rationale: The inappropriate action in collecting a midstream clean-catch urine specimen for urine analysis is to collect only 5 to 10 ml of urine. Adequate urine volume of 30 to 60 ml is required for accurate testing. Collecting a small amount like 5 to 10 ml may lead to inaccurate results due to insufficient sample size. It is crucial to follow proper collection techniques, such as discarding the first flow of urine, performing perineal care, and collecting an adequate volume, to ensure reliable test results.
The nurse prepares to administer digoxin (Lanoxin) to a newborn with a diagnosis of heart failure and notes that the apical rate is 140 beats per minute. Which nursing action is appropriate?
- A. Hold the medication
- B. Administer the digoxin
- C. Notify the healthcare provider
- D. Recheck the apical rate in 1 hour
Correct Answer: B
Rationale: An apical rate of 140 bpm is within the normal range for a newborn. Digoxin is commonly used to treat heart failure by increasing the strength and efficiency of the heart's contractions. Since the heart rate is within the normal range, there is no need to hold the medication or notify the healthcare provider. Rechecking the apical rate in an hour is unnecessary as the heart rate is not alarming. Therefore, the appropriate nursing action is to administer the digoxin.
The two members of the health care team who work closely to monitor drug-nutrient interactions are:
- A. Physician and nurse
- B. Physician and pharmacist
- C. Nurse and clinical dietitian
- D. Clinical dietitian and pharmacist
Correct Answer: D
Rationale: Clinical dietitians and pharmacists work together to manage drug-nutrient interactions. They have the expertise to understand how medications and nutrients can interact in the body, potentially affecting the effectiveness of treatment. Physicians and nurses may be involved in patient care, but when it comes to monitoring drug-nutrient interactions, the specialized knowledge of clinical dietitians and pharmacists is crucial. Nurses and physicians typically focus more on administering medications and managing overall patient care, rather than the specific interactions between drugs and nutrients.
The nurse is teaching the client diagnosed with colon cancer who is scheduled for a colostomy the next day. Which behavior indicates the best method of applying adult teaching principles?
- A. The nurse repeats the information as indicated by the client's questions
- B. The nurse teaches all the information needed by the client in one session
- C. The nurse uses a video to explain medical terms to the client
- D. The nurse waits until the client asks questions about the surgery
Correct Answer: A
Rationale: Choice A is the correct answer because repeating information and addressing the client's questions as they arise is an effective method for reinforcing learning in adults. This approach allows for immediate clarification and reinforcement of important points. Choice B is incorrect because teaching all the information in one session may be overwhelming for the client and hinder retention. Choice C is incorrect as using a video with medical terms may not necessarily address the client's specific questions or concerns. Choice D is also incorrect because waiting for the client to ask questions may lead to missed opportunities for providing crucial information and addressing uncertainties.
What intervention would be the most important for the nurse to implement for the client with a left nephrectomy?
- A. Assess the intravenous fluids for rate and volume
- B. Change the surgical dressing every day at the same time
- C. Monitor the client's medication levels daily
- D. Monitor the percentage of each meal eaten
Correct Answer: A
Rationale: The most important intervention for a client with a left nephrectomy is to assess the intravenous fluids for rate and volume. After nephrectomy, monitoring intravenous fluids is crucial to ensure proper hydration and kidney function. Changing the surgical dressing daily, monitoring medication levels, and tracking meal intake are also important aspects of care but not as critical as ensuring adequate intravenous fluid management post-surgery.