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Which finding indicates effective hemodialysis?
- A. Decreased BUN.
- B. Increased potassium.
- C. Weight gain.
- D. Hypotension.
Correct Answer: A
Rationale: Decreased BUN indicates effective removal of waste products.
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A client is admitted to the surgical floor after having bowel surgery. The nurse observes that the client's urine output has decreased from 50 to 20 mL/hour. Which of the following is the most likely cause?
- A. Bowel obstruction.
- B. Adverse effect of opioid analgesics.
- C. Hemorrhage.
- D. Hypertension.
Correct Answer: B
Rationale: Opioid analgesics, commonly used post-surgery, can cause urinary retention by relaxing the bladder, reducing urine output. This is the most likely cause in this scenario.
Prior to being transported to the surgery suite, the nurse asks the client whether he has any allergies. The client responds, 'Doesn't anyone communicate with anyone? I have been asked that question over and over!' What is the nurse's best response?
- A. œI'm sorry! I just have to ask that question for the record.'
- B. œIt's an important question and we just have to check.'
- C. œYou will hear it again and again as you go through surgery.'
- D. œThis question is asked for verification and safety with each new phase of treatment.'
Correct Answer: D
Rationale: Explaining that repeated allergy checks are for safety and verification reassures the client while clarifying the purpose of the question. This response addresses the client's frustration and emphasizes the importance of the process.
A client post-cystoscopy reports severe pain. The nurse should:
- A. Administer analgesics as prescribed.
- B. Encourage ambulation.
- C. Apply a cold pack.
- D. Notify the physician.
Correct Answer: D
Rationale: Severe pain post-cystoscopy is abnormal and requires physician notification to rule out complications.
Which of the following should the nurse include in the discharge plan for a client with multiple sclerosis who has an impaired peripheral sensation?
- A. Carefully test the temperature of bath water.
- B. Avoid kitchen activities because of the risk of injury.
- C. Avoid hot water bottles and heating pads.
- D. Inspect the skin daily for injury or pressure points.
- E. Wear warm clothing when outside in cold temperatures.
Correct Answer: A,C,D,E
Rationale: Testing bath water temperature (A), avoiding hot water bottles/heating pads (C), daily skin inspection (D), and wearing warm clothing (E) prevent injury due to impaired sensation. Avoiding kitchen activities entirely is overly restrictive.
A nurse is participating in a diabetes screening program. Who of the following is (are) at risk for developing type 2 diabetes? Select all that apply.
- A. A 32-year-old female who delivered a 9½-lb infant.
- B. A 44-year-old Native American Indian who has a body mass index (BMI) of 32.
- C. An 18-year-old Hispanic who jogs four times a week.
- D. A 55-year-old Asian American who has hypertension and two siblings with type 2 diabetes.
- E. A 12-year-old who is overweight.
Correct Answer: A,B,D,E
Rationale: Risk factors for type 2 diabetes include history of delivering a large infant, obesity (BMI >30), family history, hypertension, and being overweight, especially in youth. Regular exercise reduces risk, making the 18-year-old less likely to be at risk.