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The nurse is reinforcing teaching for a client with heart failure who has had multiple admissions to treat exacerbations. Which of the following statements by the client would require follow-up?
- A. I will begin weighing myself at the same time every day.
- B. I will eat foods high in potassium while taking furosemide.
- C. I will prepare frozen meals at home instead of eating restaurant foods.
- D. I will start incorporating moderate exercise into my daily routine.
Correct Answer: B
Rationale: High-potassium foods can cause hyperkalemia in heart failure patients, especially with certain medications, requiring follow-up. Other statements are appropriate.
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The nurse is caring for a woman whose husband beats her regularly. Which is the most important long-term goal for this woman?
- A. Provide a long-term support group
- B. Help her feel like a survivor
- C. Point out the ways she behaved
- D. Be able to blame the abuser
Correct Answer: B
Rationale: Feeling like a survivor empowers the woman, fostering resilience and self-efficacy, the most important long-term goal in domestic violence recovery.
A child with croup is placed in a cool, high-humidity tent connected to room air. The primary purpose of the tent is to:
- A. Prevent insensible water loss.
- B. Provide a moist environment with oxygen at 30%.
- C. Prevent dehydration and reduce fever.
- D. Liquefy secretions and relieve laryngeal spasm.
Correct Answer: D
Rationale: A cool, high-humidity tent liquefies secretions and relieves laryngeal spasm in croup, easing breathing. It does not primarily prevent water loss, deliver 30% oxygen, or reduce fever.
A client in the medical-surgical unit has an indwelling urinary catheter. Which actions should the nurse implement to reduce the incidence of catheter-associated urinary tract infections? Select all that apply.
- A. Cleanse periurethral area with antiseptics every shift
- B. Ensure each client has a separate container to empty collection bag
- C. Keep catheter bag below the level of the bladder
- D. Routinely irrigate the catheter with antimicrobial solution
- E. Use sterile technique when collecting a urine specimen
Correct Answer: B,C,E
Rationale: Using a separate container prevents cross-contamination. Keeping the bag below the bladder prevents urine backflow, reducing infection risk. E: Sterile technique minimizes pathogen introduction during specimen collection. A is incorrect as routine antiseptic cleansing can disrupt natural flora, increasing infection risk. D is incorrect as routine irrigation is not recommended unless medically indicated, as it can introduce pathogens.
The nurse is calculating the intake and output for a client who had a transurethral prostatectomy and is receiving continuous bladder irrigation at 175 mL/hr. The nurse empties 2300 mL of urine from the urinary drainage bag at the end of the 8-hour shift. How many mL should the nurse document as the client's net urine output for the shift? Record your answer using a whole number.
- A. 900 mL
Correct Answer: A
Rationale: Irrigation input = 175 mL/hr × 8 hr = 1400 mL. Total output = 2300 mL. Net urine output = 2300 mL - 1400 mL = 900 mL.
The doctor has ordered Polycillin (ampicillin) Suspension 150 mg every 6 hours. The suggested dose for infants is 25-50 mg/kg/day in equally divided doses. The infant weighs 7 kg. The nurse should:
- A. Give the medication as ordered
- B. Give half the amount ordered
- C. Give the ordered amount every 12 hours
- D. Check the order with the doctor
Correct Answer: D
Rationale: The ordered dose (150 mg q6h = 600 mg/day) exceeds the safe range for a 7 kg infant (175-350 mg/day), requiring the nurse to verify the order with the doctor.