Nokea
The nurse has been encouraging the intake of oral fluids for a client in labor to improve hydration. Which indicates a successful outcome of this action?
- A. Ketones in the urine
- B. A urine specific gravity of 1.020
- C. A blood pressure of 150 / 90mmHg
- D. The continued leaking of amniotic fluid during labor
Correct Answer: B
Rationale: Urine specific gravity measures the concentration of the urine. During the first stage of labor, the renal system has a tendency to concentrate urine. Labor and birth require hydration and caloric intake to replenish energy expenditure and promote efficient uterine function. An elevated blood pressure and ketones in the urine are not expected outcomes related to labor and hydration. After the membranes have ruptured, it is expected that amniotic fluid may continue to leak.
You may also like to solve these questions
The nurse has taught a client who is prescribed a xanthine bronchodilator about beverages to avoid. The nurse determines that the client understands the information if the client chooses which beverage from the dietary menu?
- A. Cola
- B. Coffee
- C. Chocolate milk
- D. Cranberry juice
Correct Answer: D
Rationale: Cola, coffee, and chocolate contain xanthine and should be avoided by the client who is taking a xanthine bronchodilator. This could lead to an increased incidence of cardiovascular and central nervous system side effects that can occur with the use of these types of bronchodilators.
The nurse is caring for a client who has returned from the postanesthesia care unit after prostatectomy. The client has a three-way Foley catheter with an infusion of continuous bladder irrigation (CBI). Which color description of the urinary drainage should lead the nurse to determine that the flow rate is adequate?
- A. Dark cherry
- B. Clear as water
- C. Pale yellow or slightly pink
- D. Concentrated yellow with small clots
Correct Answer: C
Rationale: The infusion of bladder irrigant is not at a preset rate; rather, it is increased or decreased to maintain urine that is a clear, pale yellow color or has just a slight pink tinge. The infusion rate should be increased if the drainage is cherry colored or if clots are seen. Alternatively, the rate can be slowed down slightly if the returns are as clear as water.
The nurse reviews the nursing care plan of a hospitalized preschool child who is immobilized as a result of skeletal traction. The nurse notes concerns related to the child's development because of immobilization and hospitalization. Which evaluative statement indicates a positive outcome for the child?
- A. The fracture heals without complications.
- B. The caregivers verbalize safe and effective home care.
- C. The child maintains normal joint and muscle integrity.
- D. The child displays age-appropriate developmental behaviors.
Correct Answer: D
Rationale: Regression and inappropriate developmental behaviors may be displayed in response to immobilization and hospitalization. With individualized care planning, a positive outcome of age-appropriate behavior can be achieved. The remaining options are appropriate evaluative statements for an immobilized child, but they do not directly address the child's development.
The nurse is monitoring the nutritional status of a client who is receiving enteral nutrition. Which should the nurse monitor as the best clinical indicator of the client's nutritional status?
- A. Daily weight
- B. Calorie count
- C. Skinfold measurement
- D. Serum prealbumin level
Correct Answer: D
Rationale: A serum prealbumin level is the most important parameter for determining the effectiveness of a client's nutritional management and nutritional status. Because prealbumin is a major plasma protein with a short half-life, it is sensitive to changes in protein synthesis and catabolism, and it is thus the best clinical indicator of nutritional status. It is a better nutritional index than a daily weight because body weight can be skewed quickly by changes in total body fluid. It is also a better index than anthropomorphic measurements because nutritional status is not necessarily related to skinfold thickness. The calorie count reports the total calories provided to the client without data regarding the client's use of the calories and nutrients.
A client has been taking nadolol for the past month. Which finding would indicate a therapeutic effect of the medication?
- A. The client is afebrile.
- B. The client has clear breath sounds.
- C. The client reports no episodes of headache.
- D. The client has a blood pressure of 118 / 72mmHg .
Correct Answer: D
Rationale: Nadolol is a beta-adrenergic blocking agent that is used to treat hypertension. Therefore, a blood pressure within the normal range would indicate an effective response to the medication. Based on this information the remaining options are unrelated to the action of this medication.