Nokea
The nurse is assisting the RN to develop a nursing care plan for a client who has acute glomerulonephritis. Which of the following should the nurse monitor? Select all that apply.
- A. Urine for protein
- B. Urine for specific gravity
- C. Intake and output
- D. Daily weights
- E. Blood pressure
- F. Serum electrolytes
Correct Answer: A,B,C,D,E,F
Rationale: Glomerulonephritis causes proteinuria, altered urine concentration, fluid retention, hypertension, and electrolyte imbalances; monitoring urine, intake/output, weight, BP, and electrolytes tracks disease progression and complications.
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The client is admitted to the intensive care unit with severe chest pain. Which information provides the nurse with the most data that can be utilized in planning care?
- A. The blood pressure
- B. The vital signs
- C. The pulse oximeter
- D. The EEG
Correct Answer: B
Rationale: Vital signs include blood pressure, pulse, respirations, and temperature, providing the most comprehensive data for planning care in a client with severe chest pain. Blood pressure and pulse oximeter are included in vital signs, and EEG is irrelevant for chest pain.
The nurse is caring for a post-operative client who develops a wound evisceration. The first nursing intervention should be
- A. medicate the client for pain
- B. call the provider
- C. cover the wound with sterile saline dressing
- D. place the bed in a flat position
Correct Answer: C
Rationale: When evisceration occurs, the wound should first be quickly covered by sterile dressings soaked in sterile saline. This prevents tissue damage until a repair can be effected.
A laboring woman who has dystocia is receiving oxytocin. The nurse observes a contraction lasting 90 seconds. What should the nurse do first?
- A. Slow down the rate of the oxytocin
- B. Turn the woman on her left side
- C. Give the woman oxygen
- D. Stop the oxytocin
Correct Answer: D
Rationale: Contractions longer than 60-90 seconds risk fetal hypoxia; stopping oxytocin immediately reduces uterine stimulation, prioritizing fetal safety.
Immediately after surgery the client with an above-the-knee amputation of the right leg refuses to look at the operative site. The most immediate diagnosis that can be made is:
- A. Self-care deficit
- B. Potential for infection
- C. Disturbance in self-concept
- D. Cognitive deficit
Correct Answer: C
Rationale: Refusing to look at the operative site suggests a disturbance in self-concept, as the client may be struggling with acceptance of the altered body image post-amputation.
The nurse is caring for all of the following clients. Who is probably at greatest risk for skin breakdown and will need special nursing care measures?
- A. A 75-year-old who is admitted with a broken hip
- B. An 80-year-old who is admitted with angina
- C. An 85-year-old who is admitted for diagnostic tests
- D. A 78-year-old who is admitted with asthma
Correct Answer: A
Rationale: A broken hip limits mobility, increasing pressure ulcer risk due to prolonged immobility, requiring special skin care measures.