Nokea
Which of the following assessments by the nurse would indicate that the client is having a possible adverse response to the isoniazid (INH)?
- A. Severe headache
- B. Appearance of jaundice
- C. Tachycardia
- D. Decreased hearing
Correct Answer: B
Rationale: Clients receiving INH therapy are at risk for developing drug-induced hepatitis. The appearance of jaundice may indicate that the client has liver damage.
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A client has been transferred from a nursing home to the hospital with an indwelling urinary catheter. The urine is cloudy and foul-smelling.
Which of the following nursing measures would be MOST appropriate?
- A. Clean the urinary meatus every other day.
- B. Encourage the client to increase fluid intake.
- C. Empty the drainage bag every 2-4 hours.
- D. Irrigate the Foley catheter every 8 hours.
Correct Answer: B
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) does not address the problem of the client's urine, should not be performed (2) correct-increasing intake of fluids is an appropriate independent nursing action that facilitates removal of concentrated urine (3) does not address the problem of the client's urine, should not be performed (4) could increase the chance of developing an infection
Which of the following should the nurse include in his teaching plan for the client taking Vasopressin (Lypressin)?
- A. The client will need to take her medication with meals.
- B. The client will need to learn how to check the specific gravity of her urine.
- C. The client will need to modify her daily activities.
- D. The client will need to learn the proper method of drug administration.
Correct Answer: D
Rationale: Vasopressin is often administered nasally or by injection, so teaching the proper administration method is essential.
A client is being treated for hypovolemia.
Which of the following observations should the nurse identify as the desired response to fluid replacement?
- A. Urine output 160 cc/8 h.
- B. Hgb 11 g, Hct 33%.
- C. Arterial pH 7.34.
- D. CVP reading of 8 cm of water pressure.
Correct Answer: D
Rationale: Strategy: Determine the significance of each answer choice and how it relates to hypovolemia. (1) indicates a hypovolemic state (2) indicates a hypovolemic state (3) indicates acidosis (4) correct-normal range for CVP is 3-8 cm water pressure (or 2-6 mm Hg); reading of 8 cm water pressure would indicate a desired response to fluid replacement
The nurse is caring for a client who was admitted following a motor vehicle accident. The client's blood pressure one hour ago was 118/76, and pulse was 80; now the blood pressure is 90/60, and pulse is 98. What action should the nurse take initially?
- A. Continue to monitor the blood pressure
- B. Ask another nurse to check the blood pressure reading
- C. Elevate the client's legs
- D. Call the physician
Correct Answer: D
Rationale: A significant drop in blood pressure with increased pulse suggests shock or bleeding, requiring immediate physician notification. Monitoring, rechecking, or leg elevation delays care.
An 8-year-old girl has a closed transverse fracture of her right ulna.
Which of the following actions, if performed by the nurse before the application of a cast, is MOST important?
- A. Check the radial pulses bilaterally and compare.
- B. Evaluate the skin temperature and tissue turgor in the area.
- C. Assess sensation of each foot while the girl closes her eyes.
- D. Apply baby powder to decrease skin irritation under the cast.
Correct Answer: A
Rationale: Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? Yes. (1) correct-assess neurovascular status, check pain, pallor, paralysis, paresthesia, pulselessness (2) assessment, temperature indicates decreased circulation, but is subjective and not most important (3) assessment, upper (not lower) extremity fracture (4) implementation, should not be done because it would increase skin irritation