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 post-pituitary surgery suggests diabetes insipidus due to decreased antidiuretic hormone, requiring immediate physician notification.
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The nurse is reviewing the results of a sweat test taken from a child with cystic fibrosis. Which finding supports the client's diagnosis?
- A. A sweat potassium concentration less than 40 mEq/L
- B. A sweat chloride concentration greater than 60 mEq/L
- C. A sweat potassium concentration greater than 40 mEq/L
- D. A sweat chloride concentration less than 40 mEq/L
Correct Answer: B
Rationale: A sweat chloride concentration >60 mEq/L is diagnostic for cystic fibrosis due to defective chloride channels. Potassium levels are not diagnostic, and low chloride is normal.
The nurse is caring for a client with a diagnosis of postpartum endometritis. Which vital sign change is most likely to be observed?
- A. Fever
- B. Tachycardia
- C. Hypotension
- D. All of the above
Correct Answer: D
Rationale: Postpartum endometritis a uterine infection can cause fever (from infection) tachycardia (from systemic response) and hypotension (in severe cases). All vital sign changes may be observed.
A client with a history of a kidney transplant is being discharged. The nurse should teach the client to:
- A. Monitor for signs of infection
- B. Eat a high-sodium diet
- C. Limit physical activity
- D. Take antibiotics daily
Correct Answer: A
Rationale: Immunosuppression post-kidney transplant increases infection risk, requiring vigilant monitoring. High-sodium diets, activity limits, and daily antibiotics are not standard.
The nurse is caring for a client with a history of a spinal cord injury who is experiencing autonomic dysreflexia. The nurse should:
- A. Place the client in a prone position
- B. Administer a vasodilator
- C. Insert a Foley catheter immediately
- D. Elevate the head of the bed
Correct Answer: C
Rationale: Autonomic dysreflexia is often triggered by bladder distension. Inserting a Foley catheter relieves the trigger. Vasodilators and positioning are secondary, and prone position is unsafe.
The mother of a client is apprehensive about taking home her 2 year old who was diagnosed with asthma after being admitted to the emergency room with difficulty breathing and cyanosis. She asks the nurse what symptoms she should look for so that this problem will not happen again. The nurse instructs her to watch for the following early symptoms:
- A. Fever, runny nose, and hyperactivity
- B. Changes in breathing pattern, moodiness, fatigue, and edema of eyes
- C. Fatigue, dark circles under the eyes, changes in breathing pattern, glassy eyes, and moodiness
- D. Fever, cough, paleness, and wheezing
Correct Answer: C
Rationale: The child with asthma may not have fever unless there is an underlying infection. Edema of the eyes will not be present because the child with asthma is more likely to have dehydration related to excessive water loss during the work of breathing. All of these symptoms indicate decreased oxygenation and are early symptoms of asthma. Coughing and wheezing are not early signs of difficulty.