Nokea
Which fluid is best for a client with renal calculi?
- A. Cranberry juice.
- B. Cola.
- C. Water.
- D. Milk.
Correct Answer: C
Rationale: Water increases urine volume, reducing stone formation risk.
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Which of the following family members exposed to tuberculosis would be at highest risk for contracting the disease?
- A. 45-year-old mother.
- B. 17-year-old daughter.
- C. 8-year-old son.
- D. 76-year-old grandmother.
Correct Answer: D
Rationale: The elderly (76-year-old grandmother) are at highest risk due to weakened immune systems, increasing susceptibility to tuberculosis infection. Children and younger adults are less vulnerable unless immunocompromised.
A client has a tibial fracture that required casting. Approximately 5 hours later, the client has increasing pain distal to the left tibial fracture despite the morphine injection administered 30 minutes previously. Which of the following should be the nurse's next assessment?
- A. Presence of a distal pulse.
- B. Pain with a pain rating scale.
- C. Skin temperature.
- D. Potential for drug tolerance.
Correct Answer: A
Rationale: Increasing pain despite analgesia suggests compartment syndrome; checking the distal pulse assesses for vascular compromise.
The nurse is caring for a client receiving hydromorphone via patient-controlled analgesia (PCA). The nurse should prioritize assessing the client's
- A. blood pressure.
- B. pain level.
- C. activity tolerance.
- D. bowel patterns.
Correct Answer: B
Rationale: Pain level is the priority assessment for a client on PCA with hydromorphone to ensure effective pain management and adjust dosing if needed.
A nurse is assigned to a client with venous thrombus. The nurse identifies a nursing diagnosis of Impaired physical mobility related to pain. Which should the nurse do first?
- A. Elevate the legs
- B. Elevate the legs by using a pillow under the knees
- C. Encourage adequate fluid intake
- D. Massage the lower legs
Correct Answer: A
Rationale: Elevating the legs (without knee flexion) promotes venous return, reducing pain and swelling in venous thrombus, addressing impaired mobility. Elevating with a pillow under the knees may impede flow, fluids are secondary, and massaging risks dislodging the thrombus.
The nurse assesses that the client with hepatitis is experiencing fatigue, weakness, and a general feeling of malaise. The client tires rapidly during morning care. Based on this information, which of the following would be an appropriate nursing diagnosis?
- A. Impaired physical mobility related to malaise.
- B. Self-care deficit related to fatigue.
- C. Ineffective coping related to long-term illness.
- D. Activity intolerance related to fatigue.
Correct Answer: D
Rationale: Activity intolerance related to fatigue (D) accurately reflects the client's rapid tiring due to hepatitis. Impaired mobility (A), self-care deficit (B), and ineffective coping (C) are less directly supported by the symptoms described.