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The nurse is caring for a client who had a transsphenoidal hypophysectomy and developed diabetes insipidus. Which of the following findings would the nurse expect to observe? Select all that apply.
- A. excessive thirst
- B. increased urine output
- C. increased serum osmolality
- D. decreased serum sodium level
- E. increased urine specific gravity
Correct Answer: A,B,C
Rationale: Diabetes insipidus results from antidiuretic hormone deficiency, causing excessive thirst, increased dilute urine output, and increased serum osmolality due to water loss. Serum sodium may increase, not decrease, and urine specific gravity is low due to dilute urine.
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According to the ANA Code of Ethics for Nurses, professional nurses have an ethical obligation to:
- A. clients (patients).
- B. the profession of nursing.
- C. provide high-quality care.
- D. all of the above.
Correct Answer: D
Rationale: The ANA Code of Ethics encompasses obligations to clients, the profession, and delivering high-quality care, ensuring comprehensive ethical practice. Coordinated Care
The charge nurse has a health care team that consists of 1 practical nurse (PN), 1 unlicensed assistive personnel (UAP) and 1 PN nursing student. Which assignment should be questioned by the nurse manager?
- A. An admission at the change of shifts with atrial fibrillation and heart failure - PN
- B. Client who had a major stroke 6 days ago - PN nursing student
- C. A child with burns who has packed cells and albumin IV running - charge nurse
- D. An elderly client who had a myocardial infarction a week ago - UAP
Correct Answer: A
Rationale: The care for a new admission should be performed by an RN. Since the client was admitted at the change of shifts, the stability of the client would not have been established.
The nurse is caring for an adolescent client who just had placement of an external fixation device for long-term stabilization of a fractured tibia. Which interventions should the nurse expect to implement when caring for this client? Select all that apply.
- A. Check the pins every 4 hours and turn the bolt clockwise to tighten loose pins
- B. Maintain client on bed rest until the device is removed
- C. Notify the registered nurse immediately of pin site drainage or increased pain
- D. Perform neurovascular checks every 2-4 hours for 24 hours
- E. Perform sterile pin care per institutional policy
Correct Answer: C,D,E
Rationale: Notifying the RN of drainage or pain, performing neurovascular checks, and sterile pin care prevent complications like infection or neurovascular compromise. Tightening pins is not a nursing task, and bed rest is not always required, depending on the care plan.
A 6-month old has been hospitalized for the treatment of acute diarrhea. Discharge diet includes the use of Isomil instead of Similac formula until the next clinic appointment. Which of the following statements explains the change in infant formula?
- A. Isomil is less expensive than Similac.
- B. The infant has developed a permanent lactose intolerance.
- C. Isomil is an excellent oral rehydration formula.
- D. Infants commonly have a lactose intolerance after a diarrheal illness.
Correct Answer: D
Rationale: Isomil is a soy-based formula, used temporarily after diarrheal illness because infants may develop transient lactose intolerance due to mucosal damage. Permanent lactose intolerance is rare, and Isomil is not an oral rehydration formula.
The nurse is caring for several clients who have ostomies. Which client will have the most wellformed drainage? The client whose colostomy is in the:
- A. ileum.
- B. ascending colon.
- C. transverse colon.
- D. descending colon.
Correct Answer: D
Rationale: The descending colon absorbs more water, producing well-formed, solid stool compared to the ileum (liquid), ascending colon (semi-liquid), or transverse colon (semi-formed).