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The nurse is caring for a client with a history of hyponatremia.
- A. Which intervention is most appropriate for a client with hyponatremia?
- B. Administer hypertonic saline slowly.
- C. Encourage a low-sodium diet.
- D. Restrict fluid intake.
- E. Administer a diuretic.
Correct Answer: A
Rationale: Administering hypertonic saline slowly corrects hyponatremia by raising serum sodium levels, preventing cerebral edema. Low-sodium diets worsen hyponatremia, fluid restriction is for hypervolemic cases, and diuretics are contraindicated.
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A client has an order for D5NS 1,000 mL to infuse over 8 hours. The IV set delivers 10 drops per mL. The nurse should maintain the infusion rate at:
- A. 10 drops per minute
- B. 15 drops per minute
- C. 21 drops per minute
- D. 32 drops per minute
Correct Answer: C
Rationale: Calculate: 1,000 mL / 8 hours = 125 mL/hour. 125 mL/hour × 10 drops/mL ÷ 60 minutes = 20.83 drops/minute, rounded to 21 drops/minute.
A client has a three-way Foley catheter following a transurethral resection.
The nurse would anticipate infusing irrigating solution rapidly when
- A. the urinary output is increased.
- B. bright-red drainage or clots are present.
- C. dark-brown drainage is present.
- D. the client complains of pain.
Correct Answer: B
Rationale: Strategy: Think about each answer choice. (1) not a reason to infuse irrigating solution rapidly (2) correct-three-way Foley catheter should be irrigated rapidly when bright-red drainage or clots are present; irrigation rate should be decreased to about 40 gtts/min when the drainage clears (3) not indication to infuse irrigating solution rapidly (4) not indication to infuse irrigating solution rapidly
The nurse is caring for a client with a history of diabetic ketoacidosis.
- A. Which intervention is most important for a client with diabetic ketoacidosis?
- B. Administer insulin as ordered.
- C. Restrict all oral fluids.
- D. Administer oral glucose.
- E. Monitor blood pressure every 4 hours.
Correct Answer: A
Rationale: Insulin administration corrects hyperglycemia and ketosis in diabetic ketoacidosis, the primary treatment. IV fluids are used, oral glucose is contraindicated, and blood pressure monitoring is less frequent.
An arthritic client must be able to perform tasks to manage at home alone following discharge from the hospital.
The nurse knows that to manage at home alone following discharge from the hospital, an arthritic client must be able to perform which of the following tasks?
- A. Climb up and down stairs.
- B. Lace and tie his/her shoes.
- C. Comb his/her hair and brush his/her teeth.
- D. Walk without assistance.
Correct Answer: C
Rationale: Strategy: Think about the significance of each answer choice and how it relates to arthritis. (1) stairs can be eliminated in the client's environment (2) is a modifiable problem with the use of slip-on shoes (3) correct-is part of basic hygiene and grooming that must be done daily to maintain overall health (4) is not necessary for independence; walker or wheelchair may be used
A withdrawn, depressed client sits in the day room but refuses to participate in scheduled group activities. When implementing a plan of care the nurse should:
- A. Plan activity that will allow the client to interact with a staff member.
- B. Tell the client that participation in group activities is expected.
- C. Allow the client to select an activity that he can enjoy doing alone.
- D. Ask the client to prepare a list of activities or hobbies he enjoys.
Correct Answer: A
Rationale: One-on-one interaction with a staff member encourages engagement without overwhelming a depressed client. Mandating participation may increase withdrawal. Solitary activities (C, D) do not address social isolation.