Nokea
The physician has ordered a 24-hour urine collection for a client. Which instruction should the nurse provide?
- A. Discard the first void and then collect all urine for 24 hours.'
- B. Collect all urine in a single container for 24 hours.'
- C. Refrigerate each void separately before combining.'
- D. Collect only the first and last voids of the day.'
Correct Answer: A
Rationale: For a 24-hour urine collection, the first void is discarded, and all subsequent urine is collected for exactly 24 hours to ensure accurate measurement of analytes. A single container is used, refrigeration is advised, but separate voids are not needed.
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The nurse is teaching a client with a new diagnosis of hypertension about lifestyle modifications. Which recommendation is most appropriate?
- A. Limit exercise to once a week.
- B. Reduce sodium intake.
- C. Increase caffeine consumption.
- D. Avoid stress management techniques.
Correct Answer: B
Rationale: Reducing sodium intake lowers blood pressure in hypertension by decreasing fluid retention. Exercise should be regular, caffeine avoided, and stress management encouraged.
The nurse is caring for a client with a diagnosis of gestational diabetes. Which symptom is most likely to be present?
- A. Polyuria
- B. Fetal macrosomia
- C. Both A and B
- D. Neither A nor B
Correct Answer: C
Rationale: Gestational diabetes causes maternal polyuria (from hyperglycemia) and fetal macrosomia (from fetal hyperinsulinemia). Both are common symptoms affecting mother and fetus.
The nurse is caring for a client with a history of Sjögren’s syndrome. The nurse should expect the client to have:
- A. Dry eyes and mouth
- B. Joint swelling
- C. Fever
- D. Chest pain
Correct Answer: A
Rationale: Sjögren’s syndrome is an autoimmune condition causing reduced salivary and lacrimal gland function, leading to dry eyes and mouth.
To prevent transmission of bacterial meningitis, the nurse would instruct an infected baby's mother to:
- A. Avoid touching the baby while in the room.
- B. Stay outside of the baby's room.
- C. Wear a gown and gloves and wash her hands before and after leaving the room.
- D. Wear a mask while in the room.
Correct Answer: C
Rationale: The mother should be allowed and encouraged to touch her baby. With care, transmission can be prevented. There is no need for the mother to stay outside the room. Everyone entering the baby's room should take appropriate measures to prevent transmission of pathogens. Wearing a mask will not protect against transmission of pathogens.
Decreased pulmonary blood flow, right-to-left shunting, and deoxygenated blood reaching the systemic circulation are characteristic of:
- A. Tetralogy of Fallot
- B. Ventricular septal defect
- C. Patent ductus arteriosus
- D. Transposition of the great arteries
Correct Answer: A
Rationale: Tetralogy of Fallot is the most common cyanotic heart defect, which includes a VSD, pulmonary stenosis, an overriding aorta, and ventricular hypertrophy. The blood flow is obstructed because the pulmonary stenosis decreases the pulmonary blood flow and shunts blood through the VSD, creating a right-to-left shunt that allows deoxygenated blood to reach the systemic circulation. A VSD alone creates a left-to-right shunt. The pressure in the left ventricle is greater than that of the right; therefore, the blood will shunt from the left ventricle to the right ventricle, increasing the blood flow to the lungs. No deoxygenated blood will reach the Systemic circulation. In patent ductus arteriosus, the pressure in the aorta is greater than in the pulmonary artery, creating a left-to-right shunt. Oxygenated blood from the aorta flows into the unoxygenated blood of the pulmonary artery. Transposition of the great arteries results in two separate and parallel circulatory systems. The only mixing or shunting of blood is based on the presence of associated lesions.