Nokea
The nurse is assessing a client following the removal of a pituitary tumor. The nurse notes that the urinary output has increased and that the urine is very dilute. The nurse should give priority to:
- A. Notifying the doctor immediately
- B. Documenting the finding in the chart
- C. Decreasing the rate of IV fluids
- D. Administering vasopressive medication
Correct Answer: A
Rationale: Increased dilute urine suggests diabetes insipidus, a complication of pituitary surgery, requiring immediate physician notification for evaluation and treatment.
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The nurse is caring for a client admitted to the emergency room after a fall. X-rays reveal that the client has several fractured bones in the foot. Which treatment should the nurse anticipate for the fractured foot?
- A. Application of a short inclusive spica cast
- B. Stabilization with a plaster-of-Paris cast
- C. Surgery with Kirschner wire implantation
- D. A gauze dressing only
Correct Answer: B
Rationale: A plaster-of-Paris cast is typically used to stabilize foot fractures, ensuring proper alignment and healing.
A mother tells the nurse that her daughter has become quite a collector, filling her room with Beanie babies, dolls, and stuffed animals. The nurse recognizes that the child is developing:
- A. Object permanence
- B. Post-conventional thinking
- C. Concrete operational thinking
- D. Pre-operational thinking
Correct Answer: C
Rationale: Collecting items reflects concrete operational thinking, where children (ages 7-11) organize and categorize objects systematically, per Piaget's stages.
A client with clotting disorder has an order to continue Lovenox (enoxaparin) injections after discharge. The nurse should teach the client that Lovenox injections should:
- A. Be injected into the deltoid muscle
- B. Be injected into the abdomen
- C. Aspirate after the injection
- D. Clear the air from the syringe before injections
Correct Answer: B
Rationale: Lovenox is injected into the abdomen to ensure proper subcutaneous absorption and minimize bruising.
The nurse is caring for a client receiving supplemental oxygen. The effectiveness of the oxygen therapy is best determined by:
- A. The rate of respirations
- B. The absence of cyanosis
- C. Arterial blood gases
- D. The level of consciousness
Correct Answer: C
Rationale: Arterial blood gases provide a direct measure of oxygenation and are the most accurate way to evaluate the effectiveness of oxygen therapy.
A client taking Dilantin (phenytoin) for tonic-clonic seizures is preparing for discharge. Which information should be included in the client's discharge care plan?
- A. The medication can cause dental staining.
- B. The client will need to avoid a high-carbohydrate diet.
- C. The client will need a regularly scheduled blood work.
- D. The client will need a regularly scheduled blood work.
Correct Answer: C
Rationale: Phenytoin requires regular blood work to monitor levels and prevent toxicity, which can cause side effects like gingival hyperplasia.