Nokea
The nurse is caring for a client with extracellular fluid volume deficit. Which of the following assessments would the nurse anticipate finding?
- A. bounding pulse
- B. rapid respirations
- C. oliguria
- D. neck veins are distended
Correct Answer: C
Rationale: oliguria. Kidneys maintain fluid volume through adjustments in urine volume.
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The physician has ordered O2 at 3 liters/minute for a client with emphysema. Which device will deliver the most precise level of oxygen prescribed for the client?
- A. Nasal cannula
- B. Partial rebreather mask
- C. Simple face mask
- D. Venturi mask
Correct Answer: D
Rationale: The Venturi mask will deliver the most precise level of oxygen for the client with COPD. Answer A is incorrect, because the client may lose oxygen through an open mouth. Answers B and C are incorrect, because they are not used to deliver oxygen to the client with COPD.
Spirituality affects a client's life in all of the following areas except:
- A. nutritional intake.
- B. ability to handle stress.
- C. sexual expression.
- D. genetic makeup.
Correct Answer: D
Rationale: Spirituality is a belief in or relationship with some higher power, creative force, divine being, or infinite source of energy and does not have any effect on genetic makeup.
The nurse is caring for a client at 12 weeks gestation who has a rubella titer status of nonimmune. Which of the following actions should the nurse anticipate implementing?
- A. Administering measles-mumps-rubella (MMR) vaccine now
- B. Administering MMR vaccine immediately postpartum
- C. Administering MMR vaccine in the third trimester
- D. Informing the client that an MMR vaccine is not indicated
Correct Answer: B
Rationale: MMR is contraindicated during pregnancy due to risks to the fetus. Administering it postpartum ensures immunity for future pregnancies without harming the current pregnancy.
A 35 year-old client with sickle cell crisis is talking on the telephone but stops as the nurse enters the room to request something for pain. The nurse should
- A. Administer a placebo
- B. Encourage increased fluid intake
- C. Administer the prescribed analgesia
- D. Recommend relaxation exercises for pain control
Correct Answer: C
Rationale: Administer the prescribed analgesia. Pain relief is a priority in sickle cell crisis, and prescribed analgesics are appropriate.
A client is taking tranylcypromine (Parnate) and has received dietary instruction. Which of the following food selections would be contraindicated for this client?
- A. Fresh juice, carrots, vanilla pudding
- B. Apple juice, ham salad, fresh pineapple
- C. Hamburger, fries, strawberry shake
- D. Red wine, fava beans, aged cheese
Correct Answer: D
Rationale: Red wine, fava beans, and aged cheese contain tyramine and other vasopressors that can interact with MAOIs, potentially causing malignant hypertension.