Nokea
The student nurse is listening to a lecture on serum electrolyte levels and the use of isotonic solutions. Which statement by the student nurse indicates that the teaching has been effective?
- A. 10% dextrose in water is a hypotonic solution.
- B. 3% sodium chloride solution is a hypotonic solution.
- C. 5% dextrose in water is considered an isotonic solution.
- D. 0.45% sodium chloride solution is a hypertonic solution.
Correct Answer: C
Rationale: Five percent dextrose in water is an isotonic solution, which means that the osmolality of this solution matches normal body fluids. Other examples of isotonic fluids include 0.9% sodium chloride solution (normal saline) and lactated Ringer's solution. Ten percent dextrose in water and 3% sodium chloride solution are hypertonic solutions, and 0.45% sodium chloride solution is hypotonic.
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The nurse plans care for a client with alcohol abuse disorder based on which support system?
- A. Fresh Start, is an option for families of addicts.
- B. Families Anonymous, an option for those addicted to nicotine.
- C. Al-Anon, an option for parents of children who abuse substances.
- D. Alcoholics Anonymous, a major self-help organization for the treatment of alcohol abuse.
Correct Answer: D
Rationale: Alcoholics Anonymous is a major self-help organization for the treatment of alcoholism. Option 1 is a group for families of alcoholics. Option 2 is for nicotine addicts. Option 3 is for the parents of children who abuse substances.
The nurse is caring for a client diagnosed with dementia. Which nutritional goal should the nurse plan for with this client?
- A. Client will be free of hallucinations.
- B. Client will feed self with cueing within 24 hours.
- C. Client will be able to prepare simple foods by discharge.
- D. Client will identify favorite foods by the time of discharge.
Correct Answer: B
Rationale: The correct option identifies a goal that is directly related to the client's ability to care for self. None of the remaining options are related to the client's self-care needs.
The nurse is preparing to care for an infant diagnosed with pertussis. Which priority problem should the nurse address when planning care?
- A. Infection
- B. Fluid overload
- C. Impaired sleep patterns
- D. Inability to expectorate secretions
Correct Answer: D
Rationale: The priority problem for the child with pertussis relates to adequate air exchange. Because of the copious, thick secretions that occur with pertussis and the small airways of an infant, air exchange is critical. Infection is an important consideration, but airway is the priority. A deficient fluid volume is more likely to occur in this infant because of the thick secretions and vomiting. Sleep patterns may be disturbed because of the coughing, but this is not the critical issue.
A client hospitalized after a stroke is prepared for discharge. The primary health care provider has prescribed range-of-motion (ROM) exercises for the client's right side. Which intervention should the home care nurse's plan include when planning for the client's care?
- A. Implements ROM exercises to the point of pain for the client
- B. Considers the use of active, passive, or active-assisted exercises in the home
- C. Encourages dependence on the home care nurse to complete the exercise program
- D. Develops a schedule involving ROM exercises every 3 hours during daylight hours
Correct Answer: B
Rationale: The home care nurse must consider all forms of ROM for the client. Even if the client has right hemiplegia, the client can assist with some of his or her own rehabilitative care. In addition, the goal of home care nursing is for the client to assume as much self-care and independence as possible. The nurse needs to teach so that the client becomes self-reliant. Options 1 and 4 are incorrect from a physiological standpoint.
The nurse is creating a plan of care for a client prescribed bed rest. Which intervention should the nurse include in the plan to limit the complications of prolonged immobility?
- A. Maintain the client in a supine position.
- B. Provide a daily fluid intake of 1000 mL.
- C. Limit the intake of milk and milk products.
- D. Monitor for signs of a low serum calcium level.
Correct Answer: C
Rationale: The formation of renal and urinary calculi is a complication of immobility. Limiting milk and milk products is the best measure to prevent the formation of calcium stones. A supine position increases urinary stasis; therefore, this position should be limited or avoided. Daily fluid intake should be 2000 mL or more per day. The nurse should monitor for signs and symptoms of hypercalcemia, such as nausea, vomiting, polydipsia, polyuria, and lethargy.