Nokea
Which nursing diagnosis is appropriate for a client on a fluid restriction?
- A. Excess fluid volume related to intake that exceeds fluid loss
- B. Altered comfort: dry mouth and thirst related to restricted oral fluid
- C. Risk for impaired skin integrity related to compromised circulation secondary to edema
- D. Fluid volume deficit secondary to dehydration
Correct Answer: B
Rationale: A fluid restriction often leads to dry mouth and thirst, making 'Altered comfort' the most relevant nursing diagnosis.
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What are the priority nursing interventions for a client in shock?
- A. Hypoxia
- B. Hypercapnia
- C. Acidosis
- D. Alkalosis
Correct Answer: C
Rationale: Acidosis occurs when blood pH drops below 7.35 due to an accumulation of hydrogen ions, commonly resulting from respiratory or metabolic imbalances.
A client calls to report redness to the sclera, itching of the eyes, and increased lacrimation for several hours. What should you direct the caller to do first?
- A. Please call your doctor.'
- B. Apply a cool compress to your eyes.'
- C. If you are wearing contact lenses, remove them.'
- D. Take an over-the-counter antihistamine.'
Correct Answer: C
Rationale: Removing contact lenses is the first step to prevent further irritation and allow proper assessment of the eye condition.
What is the primary goal of the circulating nurse during preparation of the operating room, transferring and positioning the patient, and assisting the anesthesia team?
- A. Avoiding any type of injury to the patient
- B. Maintaining a clean environment for the patient
- C. Providing for patient comfort and sense of well-being
- D. Preventing breaks in aseptic technique by the sterile members of the team
Correct Answer: D
Rationale: The circulating nurse ensures aseptic practices are maintained throughout the surgical procedure.
When working as a professional nurse, what is the priority for a new nurse working on an inpatient medical-surgical unit with a preceptor?
- A. Attending to holistic client needs
- B. Ensuring client safety
- C. Avoiding medication errors
- D. Providing client-focused care
Correct Answer: B
Rationale: The correct answer is B: Ensuring client safety. This is the priority for a new nurse working on an inpatient medical-surgical unit with a preceptor because safety is the foundation of nursing care. Ensuring client safety involves preventing harm, maintaining a safe environment, and implementing appropriate interventions. Attending to holistic client needs (A) and providing client-focused care (D) are important aspects of nursing practice but ensuring client safety takes precedence. Avoiding medication errors (C) is crucial for patient safety but is just one aspect of ensuring overall client safety.
A patient who had major surgery is experiencing emotional stress as well as physiologic stress from the effects of surgery. What can this stress cause?
- A. Diuresis
- B. Hyperkalemia
- C. Fluid retention
- D. Impaired blood coagulation
Correct Answer: C
Rationale: Surgical stress triggers hormonal responses leading to fluid retention.