Nokea
The nurse is assigned to a client with jaundice and collects the following data: poor appetite, nausea, and two episodes of emesis in the past 2 hours. The nurse should make which of the following nursing diagnoses?
- A. Imbalanced nutrition: Less than body requirements.
- B. Acute pain related to abdominal muscle spasms.
- C. Adult failure to thrive.
- D. Ineffective health maintenance.
Correct Answer: A
Rationale: Poor appetite, nausea, and vomiting indicate inadequate nutritional intake, supporting the diagnosis of imbalanced nutrition.
You may also like to solve these questions
The nurse is discharging a client who has been hospitalized for preterm labor. The client needs further instruction when the nurse is
- A. I think I have a bladder infection, I need to see my obstetrician.'
- B. If I have contractions, I should contact my health care provider.'
- C. Drinking water may help prevent early labor for me.'
- D. If I travel on long trips, I need to get out of the car every 4 hours.'
Correct Answer: A
Rationale: Suspecting a bladder infection requires immediate medical evaluation, not just a visit to the obstetrician, as infections can trigger preterm labor. The other statements reflect correct understanding of preterm labor management.
Which of the following techniques is correct when administering a subcutaneous injection?
- A. Use a 1-inch needle for injection.
- B. Insert the needle at a 45-degree angle to the skin.
- C. Spread the skin tightly at the injection site.
- D. Draw 0.2 mL of air into the syringe before administration.
Correct Answer: B
Rationale: A subcutaneous injection is correctly administered at a 45-degree angle (or 90 degrees for obese patients) using a 5/8-inch needle, pinching the skin, without an air bubble.
The nurse is caring for a client with a new diagnosis of glaucoma. Which medication class should the nurse expect to administer?
- A. Beta-blockers
- B. Antibiotics
- C. Corticosteroids
- D. Antihistamines
Correct Answer: A
Rationale: Beta-blockers, such as timolol, reduce intraocular pressure in glaucoma by decreasing aqueous humor production, the primary treatment goal.
You are preparing to administer a PRN medication for pain. After your assessment of the client for pain you open the narcotics cabinet with the special key. Your calculations indicate that the client will be getting 0.8 mLs of the medication and the unit dose vial is 1 mL. You discard the excess of 0.2 mLs into the sink drain and enter the client's room. After you identify the client using two unique identifiers, the client refuses the medication. You then discard the 0.8 mLs into the sink and document the client's refusal on the narcotics count record. What have you failed to do during this process?
- A. You have failed to have another nurse witness the 0.8 mLs and the 0.2 mLs of waste.
- B. You have failed to have another nurse witness the 0.8 mLs of waste.
- C. You have failed to have another nurse witness the 0.2 mLs of waste.
- D. You have failed ask another nurse to verify the calculation of the dosage.
Correct Answer: A
Rationale: Narcotic wastage (both 0.2 mL and 0.8 mL) requires a witness to ensure accountability and prevent diversion, per standard protocol.
The client is receiving propantheline bromide (Pro-Banthine) to treat cholecystitis. The nurse should evaluate the client's response to the medication by observing for which of the following adverse effects?
- A. Urine retention.
- B. Diarrhea.
- C. Hypertension.
- D. Diaphoresis.
Correct Answer: A
Rationale: Propantheline, an anticholinergic, can cause urine retention due to reduced bladder contractility. Diarrhea, hypertension, and diaphoresis are not typical side effects.