Nokea
The nurse is caring for a postoperative patient. Four hours after surgery, the patient voids 200 cc of urine with a specific gravity of 1.019. The nurse should
- A. palpate the patient's lower abdomen for distention.
- B. encourage an increased intake of oral fluids.
- C. record the time and the amount of urine.
- D. encourage the patient to void again in two hours.
Correct Answer: C
Rationale: amount and specific gravity normal (1.010-1.030)
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The nurse is caring for a 33-year-old woman after delivering an 8 lb 4 oz girl with talipes equinovarus. The woman confides to the nurse, 'I feel so bad that my baby is abnormal.' Which of the following responses by the nurse is BEST?
- A. It's understandable that you feel this way, but there are treatments to correct your baby's problem.
- B. Your baby is not really abnormal. Her feet just look different because of the way the muscles pull.
- C. You have nothing to feel guilty about. The abnormality is not your fault.
- D. Don't feel bad. You baby's abnormality can be corrected surgically.
Correct Answer: A
Rationale: accepts feelings and gives correct information, serial casting is used
The nurse is caring for a client receiving treatment for hypoparathyroidism. The nurse determines that treatment has been successful if which of the following was observed?
- A. The client's output is 1500 cc of clear straw-colored urine.
- B. The client is unable to state his name.
- C. The client denies numbness and tingling.
- D. The client loses 3 pounds in one week.
Correct Answer: C
Rationale: Hypoparathyroidism causes hypocalcemia, leading to numbness and tingling. Their absence indicates successful calcium therapy. Options A, B, and D are unrelated or indicate other issues.
The nurse observes a student nurse checking the placement of a nasogastric (NG) tube. Which of the following actions, if performed by the student nurse, would require an intervention by the nurse?
- A. Places the end of the NG tube in a cup of water and watches for bubble formation.
- B. Checks the pH of the contents aspirated from the NG tube.
- C. Positions a stethoscope on the upper abdomen and listens as air is introduced into the NG tube.
- D. Uses a large barreled syringe to aspirate for stomach contents.
Correct Answer: A
Rationale: not considered acceptable procedure
The nurse has just received report from the previous shift.
Which of the following clients should the nurse see FIRST?
- A. A client who is receiving a blood transfusion and complains of a dry mouth.
- B. A client who is scheduled to receive heparin and the PTT is 70 seconds.
- C. A client who is receiving hydroloxacin (Cipro) and complains of a high.
- D. A client who is receiving IV potassium and complains of burning at the IV site.
Correct Answer: C
Rationale: Strategy: Determine the least stable client. (1) not an immediate concern (2) PTT is within normal limits, should give medication (3) correct-indicates hypersensitivity reaction, should stop medication and notify the physician (4) should decrease rate to prevent irritation of the vein
The nurse is obtaining a health history on a client in the medical clinic. The client states, 'I think I have an ulcer.' Which of the following responses by the nurse is BEST?
- A. Do you have a burning pain in the epigastric region?
- B. Do you have sharp pain in your lower abdomen?
- C. Do you have right shoulder pain with vomiting?
- D. Do you have heartburn when you lie down?
Correct Answer: A
Rationale: Burning epigastric pain is a classic ulcer symptom, guiding further assessment. Options B, C, and D suggest other conditions.