Nokea
The nurse is administering intravenous fluids to a dehydrated patient. On the second day of care, the patient's weight has increased by 2.25 pounds. The nurse would expect that the patient's fluid intake has
- A. equaled urine output.
- B. exceeded urine output by 1 L.
- C. exceeded urine output by 2.5 L.
- D. exceeded urine output by 3 L.
Correct Answer: B
Rationale: A weight gain of 1 kg, or approximately 2.2 to 2.5 lb, is generally equivalent to 1 liter (L) of fluid retained by the body. In this case, the patient's weight gain of 2.25 pounds suggests an excess fluid retention of approximately 1 liter, indicating that the patient's fluid intake has exceeded urine output by 1 liter. Choices C and D are incorrect as they overestimate the fluid excess based on the patient's weight gain. Choice A is incorrect as it implies an exact balance between fluid intake and urine output, which is not reflected in the given weight increase.
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A client is getting out of bed for the first time since surgery. The client complains of dizziness after the nurse raises the head of the bed. Which of the following actions should the nurse take first?
- A. Checking the client's blood pressure
- B. Checking the oxygen saturation level
- C. Having the client take some deep breaths
- D. Lowering the head of the bed slowly until the dizziness is relieved
Correct Answer: D
Rationale: When a client experiences dizziness after being positioned upright for the first time post-surgery, the initial action the nurse should take is to lower the head of the bed slowly until the dizziness subsides. This maneuver helps alleviate the dizziness by allowing the body to adapt gradually to the change in position. Subsequently, the nurse should assess the client's pulse and blood pressure. Checking the blood pressure is essential to evaluate the circulatory status and rule out orthostatic hypotension as a cause of dizziness. Checking the oxygen saturation level and having the client take deep breaths are not the priority in this scenario as the primary concern is addressing the circulatory issue causing dizziness, not a respiratory problem.
A client is being prepared for transfer to the operating room. Which of the following actions should the nurse take in the care of this client at this time?
- A. Ensuring that the client has voided
- B. Administering all daily medications
- C. Practicing postoperative breathing exercises
- D. Verifying that the client has not eaten for the last 24 hours
Correct Answer: A
Rationale: The nurse should ensure that the client has voided, especially if a Foley catheter is not in place. This step is important to prevent urinary retention during the surgical procedure. Administering all daily medications just before surgery is not standard practice. The physician typically provides specific orders regarding which medications can be taken with a sip of water before surgery. Postoperative breathing exercises are usually taught after surgery to prevent complications like atelectasis. Verifying that the client has not eaten for the last 24 hours is not a standard preoperative practice; instead, the client is usually instructed to fast for a specific period before surgery to reduce the risk of aspiration during anesthesia.
A client with renal calculi is being assessed by a nurse. Which question should the nurse ask?
- A. Is there a family history of this problem?
- B. Do you consume cranberry juice?
- C. Do you urinate after sexual intercourse?
- D. Do you have burning sensation during urination?
Correct Answer: A
Rationale: When assessing a client with renal calculi, it is important for the nurse to inquire about a family history of the problem. There is a genetic predisposition associated with renal stone formation, making it essential to assess if other family members have experienced renal stones. Choices B, C, and D are not directly related to renal calculi. Consuming cranberry juice is more relevant to urinary tract health, urinating after sexual intercourse is related to preventing urinary tract infections, and experiencing a burning sensation during urination is a symptom commonly associated with urinary tract infections, not renal calculi.
A client with renal insufficiency and a low red blood cell count asks, 'Is my anemia related to the renal insufficiency?' How should the nurse respond?
- A. Red blood cells produce erythropoietin, which increases blood flow to the kidneys.
- B. Your anemia and renal insufficiency are related to inadequate vitamin D and a loss of bone density.
- C. Erythropoietin is usually released from the kidneys and stimulates red blood cell production in the bone marrow.
- D. Kidney insufficiency inhibits active transportation of red blood cells throughout the blood.
Correct Answer: C
Rationale: The correct answer is C. Erythropoietin is produced in the kidney and is released in response to decreased oxygen tension in the renal blood supply. Erythropoietin stimulates red blood cell production in the bone marrow. Anemia in renal insufficiency is often due to decreased erythropoietin production. Anemia and renal insufficiency are not manifestations of vitamin D deficiency as stated in choice B. Choice A is incorrect as erythropoietin does not increase blood flow to the kidneys. Choice D is incorrect because kidney insufficiency does not inhibit active transportation of red blood cells throughout the blood; rather, it affects erythropoietin production and subsequent red blood cell formation.
A nurse is suctioning a client through a tracheostomy tube. During the procedure, the client begins to cough, and the nurse hears a wheeze. The nurse tries to remove the suction catheter from the client's trachea but is unable to do so. What should the nurse do first?
- A. Call a code
- B. Contact the physician
- C. Administer a bronchodilator
- D. Disconnect the suction source from the catheter
Correct Answer: D
Rationale: Inability to remove a suction catheter is a critical situation that may indicate the presence of bronchospasm and bronchoconstriction, as evidenced by the client coughing and wheezing. The immediate action for the nurse is to disconnect the suction source from the catheter, allowing the catheter to remain in the trachea. By doing so, the nurse can then connect the oxygen source to the catheter to provide essential oxygenation to the client. Contacting the physician is necessary to notify them of the situation and to obtain further orders, typically for an inhaled bronchodilator to relieve the bronchospasm. Administering a bronchodilator without physician's orders is not within the nurse's scope of practice and should not be the first action. Calling a code would be excessive at this point and should only be done if the client's condition deteriorates and immediate resuscitation is required.