Nokea
The nurse is caring for clients in the prenatal clinic. The nurse would be MOST concerned if a diabetic client in the third trimester makes which of the following statements?
- A. I am taking less insulin now than I did two months ago.
- B. I am eating a large bedtime snack.
- C. I walk 15 minutes after lunch every day.
- D. I check my blood sugar two hours after each meal.
Correct Answer: A
Rationale: Decreased insulin needs in the third trimester suggest placental dysfunction, as placental hormones typically increase insulin resistance. Options B, C, and D are appropriate: bedtime snacks prevent hypoglycemia, exercise after meals manages glucose, and postprandial checks monitor hyperglycemia.
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The nurse is caring for a client with a history of bipolar disorder who is receiving lithium 300 mg PO tid. Which of the following symptoms should the nurse report immediately?
- A. Mild thirst.
- B. Tremors and confusion.
- C. Occasional diarrhea.
- D. Dry mouth.
Correct Answer: B
Rationale: Tremors and confusion suggest lithium toxicity, a medical emergency. Options A, C, and D are common side effects.
Which statement by the nurse is appropriate when giving an assignment to an unlicensed assistive personnel (UAP) to help a client ambulate for the first time after a colon resection?
- A. Have the client sit on the side of the bed before helping the client to walk.
- B. If the client is dizzy ask the client to take some slow, deep breaths.
- C. Help the client to walk in the room as often as the client wishes.
- D. When you help the client to walk, ask if any pain occurs.
Correct Answer: A
Rationale: This statement gives clear directions to the UAP about the task and is most closely associated with the information provided in the stem that this is the client's first time out of bed after surgery.
The nurse is caring for a client who is receiving IV fluids at 100 mL/hour. Which of the following findings should the nurse report immediately?
- A. Blood pressure of 130/80 mmHg.
- B. Heart rate of 80 bpm.
- C. Jugular vein distension.
- D. Urine output of 50 mL/hour.
Correct Answer: C
Rationale: Jugular vein distension suggests fluid overload, a serious complication. Options A, B, and D are normal.
A client with pneumonia.
Which of the following nursing observations would indicate a therapeutic response to the treatment?
- A. Oral temperature of 101°F (38.3°C), increased chest pain with nonproductive cough.
- B. Cough, productive of thick green sputum, client reports feeling tired.
- C. Respirations at 20 with no complaints of dyspnea, moderate amount of thin white sputum.
- D. White cell count of 10,000 mm³, urine output at 40 cc per hour, decreasing amount of sputum.
Correct Answer: C
Rationale: Strategy: Determine which answer choice indicates an improved respiratory status. (1) validates the continued presence of the infection (2) validates the continued presence of the infection (3) correct-sputum characteristics indicate a decrease in the pneumonia; is supported by respiratory status (4) does not substantiate the status of the infection
An 11-month-old baby is having trouble gaining weight after discharge from the hospital. Which of the following actions by the nurse is BEST?
- A. Observe the child at mealtime.
- B. Inquire about the child's eating patterns.
- C. Weigh the baby each month.
- D. Attempt to feed the baby for the mother.
Correct Answer: A
Rationale: Observing mealtime assesses feeding behaviors and parental interactions, identifying causes of poor weight gain. Options B, C, and D are less direct or premature.