Nokea
Which assessment is most important for a client receiving mannitol?
- A. Blood pressure.
- B. Urine output.
- C. Pain level.
- D. Pupil response.
Correct Answer: B
Rationale: Urine output is critical to monitor for mannitol's diuretic effect in reducing intracranial pressure.
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The nurse is planning a home visit for a client with hepatitis. In order to prevent transmission the nurse should focus teaching on:
- A. Proper food handling.
- B. Insulin syringe disposal.
- C. Alpha-interferon.
- D. Use of condoms.
Correct Answer: D
Rationale: Hepatitis B and C are transmitted via body fluids, so condom use (D) prevents sexual transmission. Food handling (A) is more relevant for hepatitis A. Syringe disposal (B) applies to needle-sharing risks, and alpha-interferon (C) is treatment, not prevention.
The nurse has established a goal with a client to improve mobility following hip replacement. Which of the following is a realistic outcome at the time of discharge from the surgical unit?
- A. The client can walk throughout the entire hospital with a walker.
- B. The client can walk the length of a hospital hallway with minimal pain.
- C. The client has increased independence in transfers from bed to chair.
- D. The client can raise the affected leg 6 inches with assistance.
Correct Answer: C
Rationale: Increased independence in transfers is a realistic and measurable goal for discharge.
As an initial step in treating a client with angina, the physician prescribes nitroglycerin tablets, 0.3 mg given sublingually. This drug's principal effects are produced by:
- A. Antispasmodic effects on the pericardium.
- B. Causing an increased myocardial oxygen demand.
- C. Vasodilation of peripheral vasculature.
- D. Improved conductivity in the myocardium.
Correct Answer: C
Rationale: Nitroglycerin causes vasodilation of peripheral and coronary vasculature, reducing preload and myocardial oxygen demand, relieving angina.
A client with deep vein thrombosis (DVT) has an edematous right lower extremity. The client lies on her right side frequently. Rubor is noted on the lateral aspect of the right ankle. From the data collected, the appropriate nursing diagnosis for this client would be:
- A. Activity intolerance related to complaints of pain in lower right extremity
- B. Ineffective health maintenance related to lack of knowledge about DVT
- C. Pain related to edema
- D. Risk for impaired skin integrity
Correct Answer: D
Rationale: Edema, frequent lying on the right side, and rubor (redness) indicate pressure and poor circulation, increasing the risk for skin breakdown. Risk for impaired skin integrity is the most appropriate nursing diagnosis. Activity intolerance, ineffective health maintenance, and pain are less specific to the data.
The nurse is preparing to administer ear drops to a client who is six years old. The nurse should perform which action?
- A. Pull the ear pinna down and back
- B. Position the client on their side with the ear to be treated against a pillow
- C. Pull the ear pinna up and back
- D. Place cotton directly into the ear canal after ear drop administration
Correct Answer: C
Rationale: For children over 3 years, pulling the ear pinna up and back straightens the ear canal for proper administration.