Nokea
Which of the following indicates that the client with diabetes insipidus understands how to manage care?
- A. The client will maintain normal fluid and electrolyte balance.
- B. The client will select American Diabetes Association diet correctly.
- C. The client will state dietary restrictions.
- D. The client will exhibit serum glucose level within normal range.
Correct Answer: A
Rationale: Effective management of diabetes insipidus involves maintaining fluid and electrolyte balance through medication and adequate hydration.
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A client undergoing chemotherapy tells the nurse, 'I do not want to get out of bed in the morning because I am so tired.' The nursing plan of care should include:
- A. Education on the use of Neupogen (filgrastim).
- B. Individually tailored exercise program.
- C. Weight lifting when not experiencing fatigue.
- D. Bed rest until chemotherapy is completed.
Correct Answer: B
Rationale: An individually tailored exercise program can help combat fatigue, improve energy levels, and enhance quality of life for chemotherapy patients.
When teaching a client with heart failure about preventing complications and future hospitalizations, which problems stated by the client as reasons to call the physician would indicate to the nurse that the client has understood the teaching? Select all that apply.
- A. Becoming increasingly short of breath at rest.
- B. Weight gain of 2 lb or more in 1 day.
- C. High intake of sodium for breakfast.
- D. Having to sleep sitting up in a reclining chair.
- E. Weight loss of 2 lb in 1 day.
Correct Answer: A,B,D
Rationale: Shortness of breath at rest (A), weight gain of 2 lb or more in 1 day (B), and sleeping sitting up (D) indicate worsening heart failure, requiring physician notification.
A client with renal calculi has hematuria. The nurse should:
- A. Monitor urine output.
- B. Notify the physician immediately.
- C. Restrict fluids.
- D. Apply ice to the flank.
Correct Answer: A
Rationale: Hematuria is expected with renal calculi; monitoring ensures no excessive bleeding.
When administering a thrombolytic drug to the client experiencing a myocardial infarction (MI), the nurse explains that the purpose of the drug is to:
- A. Help keep him well hydrated.
- B. Dissolve clots that he may have.
- C. Prevent kidney failure.
- D. Treat potential cardiac arrhythmias.
Correct Answer: B
Rationale: Thrombolytic drugs dissolve clots in coronary arteries, restoring blood flow to the myocardium during an MI, reducing infarct size and improving outcomes.
The nurse is assessing a 42-year-old client with cancer. He has lost 1 lb in 4 weeks. He is taking ondansetron (Zofran) for nausea. He has a temperature of 101°F (38.3°C). The fever is indicative of:
- A. Inadequate nutrition.
- B. New resistance to current antiemetic therapy.
- C. Expected response to chemotherapy treatment.
- D. Infection.
Correct Answer: D
Rationale: A fever of 101°F in a cancer patient, especially during chemotherapy, is most likely indicative of infection, which requires prompt evaluation due to immunosuppression.