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What is the best way to monitor fluid balance in a patient with kidney disease?
- A. Monitor daily weight
- B. Monitor input and output
- C. Check for edema
- D. Check urine output
Correct Answer: A
Rationale: The correct answer is to monitor daily weight. This method is the most accurate way to assess fluid balance in patients with kidney disease. Daily weight monitoring can detect even small changes in fluid balance, such as fluid retention or loss, which may not be evident through other methods. Monitoring input and output (choice B) is also important but may not provide a complete picture of fluid balance as it doesn't consider factors like insensible losses. Checking for edema (choice C) is a sign of fluid retention but may not always be present or may be difficult to assess accurately. Checking urine output (choice D) is important but may not reflect the overall fluid balance status of the patient.
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What is the priority nursing action for a patient with confusion post-surgery?
- A. Administer oxygen
- B. Reposition the patient
- C. Check oxygen saturation
- D. Perform a neurological exam
Correct Answer: A
Rationale: The correct answer is to administer oxygen. Post-surgery, confusion in a patient could be due to hypoxia, a condition where the body is deprived of an adequate oxygen supply. Administering oxygen helps address hypoxia promptly, improving oxygen levels in the body and potentially resolving the confusion. Repositioning the patient, checking oxygen saturation, and performing a neurological exam may be important interventions but addressing hypoxia with oxygen administration takes precedence as the priority action.
A nurse is assessing a client who has a new prescription for enoxaparin. Which of the following findings is a priority for the nurse to report?
- A. Platelet count of 200,000/mm³
- B. Hemoglobin level of 15 g/dL
- C. Respiratory rate of 22/min
- D. Dark, tarry stools
Correct Answer: D
Rationale: The correct answer is D. Dark, tarry stools indicate gastrointestinal bleeding, which is a serious side effect of enoxaparin that requires immediate medical attention. Reporting this finding promptly is crucial to prevent further complications. Choices A, B, and C are within normal ranges and are not directly related to the adverse effects of enoxaparin, so they do not take precedence over the urgent concern of gastrointestinal bleeding.
A nurse is planning care for a client who has a new diagnosis of heart failure. Which of the following interventions should the nurse include in the plan of care?
- A. Limit the client's fluid intake to 1,500 mL per day.
- B. Encourage the client to walk every 2 hours.
- C. Monitor the client's weight daily.
- D. Administer oxygen via nasal cannula at 2 L/min.
Correct Answer: C
Rationale: The correct intervention the nurse should include in the plan of care for a client with heart failure is to monitor the client's weight daily. Daily weight monitoring is essential to assess fluid balance and detect any signs of worsening heart failure. Limiting fluid intake to 1,500 mL per day (Choice A) may be appropriate in some cases, but it is not the initial priority for this client. Encouraging the client to walk every 2 hours (Choice B) is generally beneficial for mobility but may not be directly related to managing heart failure. Administering oxygen via nasal cannula at 2 L/min (Choice D) is a supportive measure for hypoxia but does not directly address heart failure management.
A nurse is teaching a client about home care following cataract surgery. Which of the following statements should the nurse include?
- A. You should wear a protective eye shield while sleeping.
- B. You should avoid bending over to pick things up.
- C. You should apply pressure to your eye if you feel pain.
- D. You should resume wearing your regular glasses immediately.
Correct Answer: A
Rationale: The correct answer is A: 'You should wear a protective eye shield while sleeping.' After cataract surgery, wearing a protective eye shield while sleeping is crucial to prevent accidental injury to the eye. Choice B is incorrect because patients should indeed avoid bending over, but it is not the most important instruction among the options provided. Choice C is incorrect because applying pressure to the eye if pain is felt can be harmful and should not be advised. Choice D is incorrect because patients should not resume wearing their regular glasses immediately post cataract surgery; they should wait until their healthcare provider permits.
A patient is receiving chemotherapy and has developed stomatitis. Which of the following dietary recommendations should the nurse make?
- A. Eat salty foods to stimulate salivation.
- B. Avoid spicy foods.
- C. Increase intake of high-fiber foods.
- D. Consume cold foods to soothe the mucosa.
Correct Answer: D
Rationale: Correct choice: Consume cold foods to soothe the mucosa. Cold foods can help soothe the mucosa and reduce discomfort for patients with stomatitis caused by chemotherapy.\nIncorrect choices: A) Salty foods may irritate the mucosa further. B) Spicy foods can increase discomfort and irritation. C) High-fiber foods may be rough and abrasive, exacerbating the condition.