Nokea
When obtaining the nursing history of a client who has diabetes mellitus, the nurse should assess the client for which of the following early symptom of renal insufficiency?
- A. Polyuria
- B. Oliguria
- C. Anuria
- D. Dysuria
Correct Answer: A
Rationale: Polyuria is an early symptom of renal insufficiency in diabetes due to impaired kidney function affecting urine concentration. Oliguria, anuria, and dysuria are later or less specific.
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A postoperative client has a Jackson-Pratt drain. Which finding should the nurse report immediately?
- A. Clear, serous drainage.
- B. Bright red drainage of 50 mL in 2 hours.
- C. Slight swelling around the drain site.
- D. Drainage with a foul odor.
Correct Answer: B
Rationale: Bright red drainage suggests active bleeding, a serious complication requiring immediate reporting.
A client with gastroesophageal reflux disease (GERD) reports chest discomfort that feels like heartburn, especially following each meal. After teaching the client to take antacids as prescribed, the nurse suggests that the client lie in which position during sleep?
- A. Prone with the head of the bed flat
- B. Supine with the head of the bed flat
- C. On the left side with the head of the bed flat
- D. With the head of the bed elevated 8 to 12 inches
Correct Answer: D
Rationale: The discomfort of reflux is aggravated by positions that allow the reflux of gastrointestinal contents. The client is instructed to remain upright for 1 to 2 hours after a meal and sleep with the head of the bed elevated to approximately 30 degrees (usually on 8- to 12-inch blocks). Lying flat will increase the episodes of reflux, resulting in chest discomfort.
The nurse is assessing a client with a suspected tension pneumothorax. Which of the following interventions is the highest priority?
- A. Administer oxygen.
- B. Prepare for needle decompression.
- C. Obtain a chest X-ray.
- D. Start an IV line.
Correct Answer: B
Rationale: Preparing for needle decompression is the highest priority in tension pneumothorax to relieve pressure and restore lung function.
Which of the following is an example of beliefs of traditional Chinese medicine found in a small amount of the treatment?
- A. Health is described as harmony between family members.
- B. Illness is caused by an imbalance of the yin and yang.
- C. Exercise to the point of overexertion can improve health.
- D. Illness is caused by a change in eating habits.
Correct Answer: B
Rationale: Traditional Chinese medicine attributes illness to an imbalance of yin and yang.
The nurse is assessing fetal presentation in a multiparous client. The fi gure below indicates which of the following types of presentations?
- A. Frank breech.
- B. Complete breech.
- C. Footling breech.
- D. Vertex.
Correct Answer: C
Rationale: Although breech presentations are rare, footling breech occurs when there is an extension of the fetal knees and one or both feet protrude through the pelvis. In frank breech, there is flexion of the fetal thighs and extension of the knees. The feet rest at the sides of the fetal head. In complete breech, there is fl exion of the fetal thighs and knees; the fetus appears to be squatting. Vertex position occurs in 95% of deliveries; in such cases, the head is engaged in the pelvis.