Nokea
The nurse is assessing a client with suspected dehydration. Which finding is most indicative?
- A. Increased urine output
- B. Dry mucous membranes
- C. Bradycardia
- D. Fever
Correct Answer: B
Rationale: Dry mucous membranes are a classic sign of dehydration due to reduced fluid volume. Decreased (not increased) urine output, tachycardia, and fever may occur but are less specific.
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The nurse is caring for a client with pneumonia who is allergic to penicillin. Which antibiotic is safest to administer to this client?
- A. Cefazolin (Ancef)
- B. Amoxicillin
- C. Erythrocin (Erythromycin)
- D. Ceftriaxone (Rocephin)
Correct Answer: C
Rationale: Erythromycin, a macrolide, is safe for penicillin-allergic patients. Cefazolin (A), Amoxicillin (B), and Ceftriaxone (D) are beta-lactams with cross-reactivity risks.
A client with a history of chronic kidney disease is admitted with complaints of edema. The nurse should expect the client to have:
- A. Hypernatremia
- B. Hyponatremia
- C. Hyperkalemia
- D. Hypokalemia
Correct Answer: C
Rationale: Chronic kidney disease impairs potassium excretion, leading to hyperkalemia, which can cause cardiac complications.
The nurse is caring for a client with a history of heart failure. Which discharge instruction is most important?
- A. Weigh yourself daily.'
- B. Limit exercise to 10 minutes daily.'
- C. Increase sodium intake.'
- D. Take over-the-counter pain relievers as needed.'
Correct Answer: A
Rationale: Daily weight monitoring detects fluid retention early in heart failure, allowing timely intervention. Exercise should be moderate, sodium restricted, and pain relievers used cautiously.
A client with BPH has undergone a TURP. Which nursing interventions are parts of the client's post-operative care?
- A. Monitoring the client's vital signs
- B. Maintaining constant bladder irrigation
- C. Limiting fluid intake to 1000 mL per day
- D. Checking for post-operative bleeding
- E. Maintaining bed rest for 48 hours
Correct Answer: A, B, D
Rationale: Post-TURP care includes monitoring vital signs (A), constant bladder irrigation (B) to prevent clots, and checking for bleeding (D). Fluid intake is encouraged (C), and bed rest is typically 24 hours (E).
The nurse is preparing a client with an axillopopliteal bypass graft for discharge. The client should be taught to avoid:
- A. Using a recliner to rest
- B. Resting in supine position
- C. Sitting in a straight chair
- D. Sleeping in right Sim's position
Correct Answer: C
Rationale: Clients with an axillopopliteal bypass graft should avoid prolonged sitting in a straight chair, as it can compress the graft and impair blood flow. Reclining, supine, or Sim’s positions are less likely to compromise the graft.