Nokea
The nurse is preparing the plan of care for a client with fluid volume deficit. Which interventions should the nurse include in the plan of care?
- A. Monitor vital signs every two (2) hours until stable
- B. Weigh the client in the same clothing at the same time daily
- C. Administer mouth care every eight (8) hours
- D. A, B, and C
Correct Answer: D
Rationale: The correct interventions to include in the plan of care for a client with fluid volume deficit are monitoring vital signs every two hours until stable, weighing the client in the same clothing at the same time daily, and assessing skin turgor. These interventions are crucial for managing and detecting fluid volume changes. Administering mouth care every eight hours is not directly related to managing fluid volume deficit and does not address the key aspects of monitoring and assessing fluid status, making it an incorrect choice.
You may also like to solve these questions
The system used at the division level and forward comprises six basic modules. Which module is staffed with two surgeons, two nurse anesthetists, a medical/surgical nurse, two operating room specialists, and two practical nurses?
- A. Treatment squad
- B. Area support squad
- C. Medical service squad
- D. Forward surgical team
Correct Answer: D
Rationale: The correct answer is D, Forward Surgical Team (FST). The FST is staffed with two surgeons, two nurse anesthetists, a medical/surgical nurse, two operating room specialists, and two practical nurses. This specialized team is designed to provide immediate surgical care close to the frontline. Choices A, B, and C are incorrect as they do not match the specific composition of personnel described in the question.
The client is admitted to the emergency department complaining of acute epigastric pain and reports vomiting a large amount of bright red blood at home. Which interventions should the nurse implement?
- A. Assess the client's vital signs
- B. Start an IV with an 18-gauge needle
- C. Begin iced saline lavage
- D. A, B
Correct Answer: D
Rationale: The correct interventions for a client presenting with acute epigastric pain and vomiting bright red blood are to assess the client's vital signs and start an IV with an 18-gauge needle. Assessing vital signs helps in determining the client's current condition and response to treatment, while starting an IV is crucial for administering medications and fluids. Beginning iced saline lavage is not appropriate in this situation as the priority is to stabilize the client and address potential bleeding. Therefore, options A and B are correct choices, making option D the most appropriate answer.
Which nursing action(s) can result in disciplinary action by state boards of nursing?
- A. Release of client health information to a client's neighbor
- B. Delegation of a dressing change to unlicensed assistive personnel (UAP)
- C. Release of client health information to the client's durable power of attorney
- D. A, B
Correct Answer: D
Rationale: The correct answer is D. Disclosing client health information to unauthorized individuals like a client's neighbor (A) and improper delegation of tasks to unlicensed personnel (B) are serious violations of patient confidentiality and safety standards, which can lead to disciplinary action by state boards of nursing. Choice C, releasing client health information to the client's durable power of attorney, is not a violation as it involves sharing information with an authorized individual. Therefore, choices A and B are incorrect, making D the correct answer.
AND Answers
- A. The nurse scoop the specimen specifically at the site
- B. She took around 1 inch of specimen or a teaspoonful
- C. Ask the client to call her for the specimen after the
- D. Ask the client to defecate in a bedpan, Secure a
Correct Answer: B
Rationale: When collecting a stool specimen, the nurse should usually take about 1 inch of the specimen or a teaspoonful for testing purposes. This amount is sufficient for laboratory analysis and helps ensure accurate results. It is important for the nurse to follow the proper procedure for specimen collection to maintain accuracy in diagnostic testing.
Three major causes of atherosclerosis are:
- A. Hyperthyroidism, underweight, and poor appetite
- B. High blood cholesterol, high blood pressure, and cigarette smoking
- C. Constipation, peptic ulcer disease, and pancreatitis
- D. Kidney failure, edema, and sodium retention
Correct Answer: B
Rationale: Atherosclerosis is primarily caused by high blood cholesterol, high blood pressure, and cigarette smoking. These factors contribute to the buildup of plaque in the arteries. Choices A, C, and D are incorrect. Hyperthyroidism, underweight, and poor appetite do not directly cause atherosclerosis. Similarly, constipation, peptic ulcer disease, pancreatitis, kidney failure, edema, and sodium retention are not among the primary causes of atherosclerosis.