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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A client is started on doxepin hydrochloride (Sinequan) 75 mg PO tid. The nurse should recommend a change in the client's therapy if which of the following occurs?
- A. The client refuses to speak and sits quietly in the room.
- B. The client becomes excitable and develops tremors.
- C. The client refuses to eat breakfast.
- D. The client sleeps 18 hours a day.
Correct Answer: B
Rationale: doxepin HCL (Sinequan) is an antidepressant; signs of overdosage include excitability and tremors
The nurse is supervising a student nurse teach a client about a newly prescribed medication. Which of the following actions, if observed by the nurse, would require an intervention?
- A. The student nurse glances at his/her watch when instructing the client.
- B. The student nurse uses culturally appropriate language and teaching materials.
- C. The student nurse begins instructions to the client discussing information that concerns the client.
- D. The student nurse chooses a time for teaching when there are no visitors.
Correct Answer: A
Rationale: lack of attending behaviors are always a barrier to learning
The nurse is preparing a client for a herniorrhaphy. It would be MOST important for the nurse to complete which of the following one hour prior to surgery?
- A. Administer an enema.
- B. Confirm that the consent form has been signed.
- C. Perform a preoperative shave and scrub.
- D. Evaluate for food or medication allergies.
Correct Answer: B
Rationale: surgical consent should be rechecked prior to going to surgery
The nurse is caring for a client with a history of congestive heart failure.
- A. Which instruction is most important for a client with congestive heart failure?
- B. Weigh yourself daily at the same time.
- C. Take extra diuretics if you feel short of breath.
- D. Eat a high-sodium diet to maintain electrolytes.
- E. Avoid exercise to prevent cardiac strain.
Correct Answer: A
Rationale: Daily weight monitoring detects fluid retention early, a key indicator of worsening heart failure. Extra diuretics require medical orders, high-sodium diets worsen fluid retention, and exercise is encouraged within limits.
The nurse is leading a class for expectant mothers.
Which of the following comments would indicate to the nurse that a pregnant woman understands the recommended dietary caloric increase for pregnancy?
- A. I will need to double my calorie intake since I am now eating for two of us.'
- B. I can add an additional 500 calories by drinking milkshakes.'
- C. I need to add 300 calories by increasing my intake of the four basic food groups.'
- D. I really need to watch my calorie intake so I will not gain too much weight.'
Correct Answer: C
Rationale: Strategy: Determine the outcome of each answer choice. Is it desired? (1) common misconception (2) 500 calories is too many calories, and a milkshake is not a good food source because of its fat content (3) correct-recommended to increase calorie intake by 300 for fetal growth, maternal tissues, and the placenta (4) unsafe for the pregnant client