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Which nursing question would elicit the most thorough assessment data regarding the client's recent sleeping patterns?
- A. Are you sleeping well at home?
- B. Did you get much sleep last night?
- C. May we talk about how you've been sleeping?
- D. Do you think you get enough sleep on a nightly basis?
Correct Answer: C
Rationale: Option 3 is a question and provides the client the opportunity to express thoughts and feelings. The remaining options could lead to a one-word answer that would not provide thorough assessment data. Additionally, one night of sleep may not tell the nurse how the pattern has been over time.
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A client who has experienced an acute kidney injury is prescribed a fluid restriction of 1500 mL per day. Which interventions will the nurse implement to assist the client in maintaining this restriction? Select all that apply.
- A. Removing the water pitcher from the bedside
- B. Using mouthwash with alcohol for mouth care
- C. Prohibiting beverages with sugar to minimize thirst
- D. Providing the client with lip balm to keep lips moist
- E. Offering the client ice chips at intervals during the day
Correct Answer: A,D,E
Rationale: The nurse can help the client maintain fluid restriction through a variety of means. The water pitcher should be removed from the bedside to aid in compliance. The use of ice chips and lip ointments is another intervention that may be helpful to the client on fluid restriction. Frequent mouth care is important; however, alcohol-based products should be avoided because they are drying to mucous membranes. Beverages that the client enjoys are provided and are not restricted based on sugar content.
A clinic nurse is caring for a client with a suspected diagnosis of gestational hypertension. The nurse assesses the client, expecting to note which set of findings if gestational hypertension is present?
- A. Edema, ketonuria, and obesity
- B. Edema, tachycardia, and ketonuria
- C. Glycosuria, hypertension, and obesity
- D. Elevated blood pressure and proteinuria
Correct Answer: D
Rationale: Gestational hypertension is the most common hypertensive disorder in pregnancy. It is characterized by the development of hypertension and proteinuria. Glycosuria and ketonuria occur in diabetes mellitus. Tachycardia and obesity are not specifically related to diagnosing gestational hypertension. Edema is not specific to gestational hypertension and can occur in many disorders.
The nurse prepares to transfer the client with a newly applied arm cast into the bed using which method?
- A. Placing ice on top of the cast
- B. Supporting the cast with the fingertips only
- C. Asking the client to support the cast during transfer
- D. Using the palms of the hands and soft pillows to support the cast
Correct Answer: D
Rationale: The palms or the flat surface of the extended fingers should be used when moving a wet cast to prevent indentations. Pillows are used to support the curves of the cast to prevent cracking or flattening of the cast from the weight of the body. Half-full bags of ice may be placed next to the cast to prevent swelling, but this would be done after the client is placed in bed. Asking the client to support the cast during transfer is inappropriate.
The nurse has a prescription to administer amphotericin B intravenously to the client diagnosed with histoplasmosis. Which should the nurse specifically plan to implement during administration of the medication to minimize the client's risk for injury? Select all that apply.
- A. Monitor for hyperthermia.
- B. Monitor for an excessive urine output.
- C. Administer a concurrent fluid challenge.
- D. Assess the intravenous (IV) infusion site.
- E. Assess the chest and back for a red, itchy rash.
- F. Monitor the client's orientation to time, place, and person.
Correct Answer: A,D
Rationale: Amphotericin B is an antifungal medication and is a toxic medication, which can produce symptoms during administration such as chills, fever (hyperthermia), headache, vomiting, and impaired renal function (decreased urine output). The medication is also very irritating to the IV site, commonly causing thrombophlebitis. The nurse administering this medication monitors for these complications. Administering a concurrent fluid challenge is not necessary. A rash or disorientation is not specific to this medication.
An echocardiogram, chest x-ray (CXR), and computed axial tomography (CAT) scan are prescribed for a client who has activity intolerance. In which order should the nurse plan to schedule the procedures to meet the needs of this client safely and effectively?
- A. CAT scan and CXR in the morning, and echocardiogram on the following morning
- B. CXR and echocardiogram together in the morning, and CAT scan in the afternoon of the same day
- C. Echocardiogram in the morning, and CXR and CAT scans together in the afternoon of the same day
- D. CXR in the morning, echocardiogram in the afternoon, and CAT scan in the morning of the following day
Correct Answer: D
Rationale: CAT scans are always performed in radiology, and CXR and echocardiograms can be done at the bedside; however, the best results usually occur when the test is performed in the related department. As long as the client is stable and transportation is provided, the nurse can schedule each procedure in its department with two procedures on the first day separated by a rest period, and the remaining procedure the next day.