Nokea
The output from a client's indwelling catheter is 500 mL for the past 10 hours. The nurse should:
- A. Do nothing because the output is within normal limits.
- B. Notify the doctor because the output is too low.
- C. Replace the indwelling catheter.
- D. Force fluids to increase the output in the next 8 hours.
Correct Answer: A
Rationale: Urine output of 500 mL in 10 hours (50 mL/hour) is within normal limits (30-50 mL/hour). No intervention is needed.
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A nurse is to present information about Chinese folk medicine to a group of student nurses. Based on this cultural belief system, the nurse would explain that illness is attributed to the
- A. Yang, the positive force that represents light, warmth, and fullness
- B. Yin, the negative force that represents darkness, cold, and emptiness
- C. Use of improper hot foods, herbs and plants
- D. A failure to keep life in balance with nature and others
Correct Answer: B
Rationale: Yin, the negative force that represents darkness, cold, and emptiness. Excessive Yin is believed to cause illness in Chinese folk medicine.
Which statement describes factors that help build personal power in an organization?
- A. Longevity in an organization, social ties to people in power, and a history as someone who does not back down in conflict ends with success
- B. Goals are met with the use of networking, mentoring, and coalition building
- C. High visibility and formal power are maintained with a confrontational style
- D. Credibility to one's position is enhanced when professional dress and demeanor are employed
Correct Answer: B
Rationale: Networking, mentoring, and coalition building are positive uses of personal power to meet goals.
The nurse is planning care for a client with increased intracranial pressure. The best position for this client is
- A. Trendelenburg
- B. Prone
- C. Semi-Fowlers
- D. Side-lying with head flat
Correct Answer: C
Rationale: Semi-Fowlers. Maintaining the head of the bed at 15-30 degrees reduces cerebral venous congestion, helping to manage increased intracranial pressure.
The nurse is caring for an adult who has ulcerative colitis. When planning care, the nurse knows that which nursing diagnosis is of highest priority?
- A. Deficient fluid volume
- B. Disturbed body image
- C. Risk for impaired skin integrity
- D. Risk for ineffective health maintenance
Correct Answer: A
Rationale: Ulcerative colitis causes diarrhea, leading to fluid loss and dehydration, making deficient fluid volume the highest priority to prevent systemic complications like hypovolemia.
Which of the following clients is at greatest risk for postpartal hemorrhage?
- A. A gravida 1 para 1 with an uncomplicated delivery of a 7-pound infant
- B. A gravida 1 para 0 with a history of polycystic ovarian disease
- C. A gravida 2 para 2 with a history of low birth weight infants
- D. A gravida 4 para 3 with a Caesarean section
Correct Answer: D
Rationale: A gravida 4 para 3 with a Caesarean section is at higher risk for postpartal hemorrhage due to multiparity and surgical delivery, which can lead to uterine atony and increased bleeding risk.