Nokea
Which of the following assessment finding is typical of extracellular fluid loss?
- A. Distended jugular veins
- B. Elevated hematocrit level
- C. Rapid thready pulse
- D. Increased serum sodium level
Correct Answer: C
Rationale: Extracellular fluid loss (e.g., dehydration) reduces blood volume, causing a rapid, thready pulse as the heart compensates for hypovolemia. Distended jugular veins suggest fluid overload, not loss. Elevated hematocrit reflects hemoconcentration, but pulse is a more immediate sign. Increased sodium occurs with water loss, not always fluid volume. Nurses monitor pulse to detect early shock, guiding fluid replacement to restore circulation and prevent organ damage.
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You are doing the evaluation step of the nursing process and find that two of the goals for the client have not been met. Which of the following actions would be best on your part?
- A. Stop working on these goals, as evaluation is the last step.
- B. Assess client's motivation for complying with the care plan.
- C. Reassess problem and then review care plan and revise as needed.
- D. Determine if the client has a knowledge deficit causing nonattainment.
Correct Answer: C
Rationale: When goals aren't met during evaluation, reassessing the problem and revising the care plan is the best action. This step identifies why outcomes like reduced swelling failed, perhaps due to an outdated intervention, and adjusts accordingly. Stopping assumes evaluation ends the process, ignoring its cyclical nature. Assessing motivation or knowledge deficits might inform revisions but isn't comprehensive without reassessment. This approach ensures care evolves with the client's condition, maintaining relevance and efficacy in the nursing process.
The nurse prepares to administer buccal medication. The medicine should be placed...
- A. On the client's skin
- B. Between the client's cheeks and gums
- C. Under the client's tongue
- D. On the client's conjunctiva
Correct Answer: B
Rationale: Buccal medication is placed between the cheeks and gums for absorption.
She was the daughter of Hungarian kings, who feed 300-900 people everyday in their gate, builds hospitals, and care of the poor and sick herself.
- A. Elizabeth
- B. Catherine
- C. Nightingale
- D. Sairey Gamp
Correct Answer: A
Rationale: Saint Elizabeth of Hungary, a 13th-century princess, devoted her life to feeding the poor and building hospitals e.g., using royal funds for charity. Unlike Catherine, Nightingale (modern nurse), or Gamp (fictional), she's nursing's patron saint, her altruism inspiring early caregiving traditions in Christian nursing history.
Which of the following do not correctly correlates the increase BP of Ms. Aida, a 70 year old diabetic?
- A. Females, after the age 65 tends to have lower BP than males
- B. Disease process like Diabetes increase BP
- C. BP is highest in the morning, and lowest during the night
- D. Africans, have a greater risk of hypertension than Caucasian and Asians.
Correct Answer: A
Rationale: Females over 65 often have higher BP e.g., post-menopause than males, not lower, contradicting Aida's rise. Diabetes (vessel damage), morning peaks (circadian), and African risk (genetics) align. Nurses note this e.g., in elderly diabetics for accurate hypertension management.
The nurse is providing dietary teaching for a client with a history of nephrotic syndrome. Which food should the client be instructed to avoid?
- A. Baked chicken breast
- B. Canned chicken noodle soup
- C. Fresh apple slices
- D. Steamed broccoli
Correct Answer: B
Rationale: Canned chicken noodle soup, high in sodium, worsens edema in nephrotic syndrome baked chicken, apples, and broccoli are low-sodium and protein-friendly. Nurses teach sodium restriction, reducing fluid retention, supporting kidney function in this protein-losing condition.