Nokea
The nurse is calculating the intake and output for a client who had a transurethral prostatectomy and is receiving continuous bladder irrigation at 175 mL/hr. The nurse empties 2300 mL of urine from the urinary drainage bag at the end of the 8-hour shift. How many mL should the nurse document as the client's net urine output for the shift? Record your answer using a whole number.
- A. 900 mL
Correct Answer: A
Rationale: Irrigation input = 175 mL/hr × 8 hr = 1400 mL. Total output = 2300 mL. Net urine output = 2300 mL - 1400 mL = 900 mL.
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At the day treatment center a client diagnosed with schizophrenia - paranoid type sits alone alertly watching the activities of clients and staff. The client is hostile when approached and asserts that the doctor gives her medication to control her mind. The client's behavior most likely indicates
- A. Feelings of increasing anxiety related to paranoia
- B. Social isolation related to altered thought processes
- C. Sensory perceptual alteration related to withdrawal from environment
- D. Impaired verbal communication related to impaired judgment
Correct Answer: B
Rationale: Social isolation related to altered thought processes. Hostility and lack of engagement suggest isolation driven by paranoid thoughts.
The nurse is reinforcing teaching for the parents of a child newly diagnosed with hemophilia. Which long-term complication is important for the nurse to discuss?
- A. Heart valve injury
- B. Intellectual disability
- C. Joint destruction
- D. Recurrent pneumonia
Correct Answer: C
Rationale: Hemophilia causes recurrent joint bleeds, leading to joint destruction (hemophilic arthropathy), a key long-term complication.
A child with croup is placed in a cool, high-humidity tent connected to room air. The primary purpose of the tent is to:
- A. Prevent insensible water loss.
- B. Provide a moist environment with oxygen at 30%.
- C. Prevent dehydration and reduce fever.
- D. Liquefy secretions and relieve laryngeal spasm.
Correct Answer: D
Rationale: A cool, high-humidity tent liquefies secretions and relieves laryngeal spasm in croup, easing breathing. It does not primarily prevent water loss, deliver 30% oxygen, or reduce fever.
The client recently admitted to the assisted living center has impaired vision related to primary open-angle glaucoma. Select the graphic that best illustrates the effects of glaucoma on the client's vision.
Correct Answer: B
Rationale: Glaucoma causes peripheral vision loss (tunnel vision), best depicted by a graphic showing a narrowed visual field. Specific graphic not provided.
The nurse has reinforced teaching with the parents of a 6-year-old client with chronic allergic rhinitis that is triggered by dust and pollen. Which of the following statements by the parents would indicate a correct understanding of the teaching? Select all that apply.
- A. We are planning to purchase an air purifier with a high-efficiency particulate air filter
- B. We will keep the windows open during warm weather to air out our house.
- C. We should place hypoallergenic covers on our child's mattress and pillow.
- D. We will clean our wood floors with a damp mop at least once a week
- E. We are planning to remove the carpet from our child's bedroom.
Correct Answer: A,C,D,E
Rationale: Correct choices reduce allergen exposure: HEPA filters remove dust/pollen, hypoallergenic covers prevent dust mite exposure, damp mopping reduces dust, and removing carpets eliminates allergen reservoirs. Keeping windows open increases pollen exposure, worsening symptoms.