Nokea
The nurse is caring for a post myocardial infarction client in an intensive care unit. It is noted that urinary output has dropped from 60 -70 ml per hour to 30 ml per hour. This change is most likely due to:
- A. Dehydration.
- B. Diminished blood volume.
- C. Decreased cardiac output.
- D. Renal failure.
Correct Answer: C
Rationale: Decreased cardiac output reduces kidney perfusion, affecting urine output.
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What sign would you expect to find when assessing Mr. Stout with chronic bronchitis?
- A. Loss of weight
- B. Chronic cough
- C. Barrel chest
- D. Scanty sputum
Correct Answer: B
Rationale: Chronic cough is a hallmark symptom of chronic bronchitis.
What will certification in nursing require and/or provide (select all that apply)?
- A. A certain amount of clinical experience
- B. Successful completion of an examination
- C. Membership in specialty nursing organizations
- D. Professional recognition of expertise in a specialty area
Correct Answer: A
Rationale: Certification typically requires clinical experience and passing an exam. It provides professional recognition but does not mandate membership in specialty organizations.
The trauma unit nurse has received a report on a client who has multiple injuries following a motor vehicle crash. Which of the following actions should the nurse plan to take first?
- A. Evaluate chest expansion.
- B. Check pupillary response to light.
- C. Assess the capillary refill.
- D. Check the client's response to questions about place and time.
Correct Answer: A
Rationale: The correct answer is A: Evaluate chest expansion. This is the priority action because it assesses the client's airway and breathing, which are critical for survival. Checking chest expansion helps to identify any potential respiratory compromise or underlying lung injuries. Assessing pupillary response (B) and capillary refill (C) are important, but they are secondary to ensuring adequate oxygenation. Checking the client's orientation to place and time (D) is important for neurological assessment but is not as critical as assessing airway and breathing in this scenario.
Identify one example of how each of the following cultural factors may affect the nursing care of a patient of a different culture and one example of the functioning of a health care team made up of individuals from different cultures.
- A. Time orientation
- B. Economic factors
- C. Nutrition
- D. Personal space
Correct Answer: D
Rationale: This question requires subjective examples based on individual interpretation. For instance, time orientation might influence punctuality expectations in patients and collaboration within diverse teams.
Karen is suspected of having a hormone imbalance. What would you expect to monitor
- A. Electrolyte levels.
- B. Thyroid studies, follicle-stimulating hormone (FSH), and luteinizing hormone (LH).
- C. Caloric intake.
- D. All of the above.
Correct Answer: D
Rationale: Hormonal imbalances affect multiple systems and require comprehensive monitoring.