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A nurse is collecting data from a client who has dehydration. Which of the following findings should the nurse expect?
- A. Cool skin
- B. Bradycardia
- C. Urine output 20 mL/hr
- D. Sodium 142 mEq/L
Correct Answer: C
Rationale: The correct answer is C: Urine output 20 mL/hr. In dehydration, the body tries to conserve water, leading to decreased urine output. This finding indicates the body's attempt to retain fluids. A: Cool skin is incorrect as dehydration often presents with warm, dry skin due to decreased sweating. B: Bradycardia is unlikely in dehydration as the body tries to maintain cardiac output by increasing heart rate. D: A normal sodium level of 142 mEq/L does not specifically indicate dehydration.
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A nurse is reinforcing teaching with a client who reports constipation. Which of the following should the nurse discuss as causes of constipation? (Select all that apply.)
- A. Excessive laxative use
- B. Ignoring the urge to defecate
- C. Inadequate fluid intake
- D. Increased fiber in the diet
- E. Increased activity
Correct Answer: A,B,C
Rationale: The correct answer is A, B, and C. A: Excessive laxative use can lead to constipation by causing dependency on laxatives. B: Ignoring the urge to defecate can disrupt the normal bowel movement pattern, leading to constipation. C: Inadequate fluid intake can result in hard, dry stools that are difficult to pass, causing constipation. D: Increased fiber in the diet actually helps prevent constipation by adding bulk to the stool. E: Increased activity generally promotes bowel regularity and helps prevent constipation. By discussing A, B, and C with the client, the nurse can address common causes of constipation and provide appropriate interventions.
The family of a client who has died unexpectedly arrives immediately after the death. Which of the following actions should the nurse take?
- A. Ask the family to return after the staff cleans the body.
- B. Perform postmortem care so that the body is prepared for the funeral home.
- C. Have a clergy member present when the family first sees the client.
- D. Allow the family to view the body privately.
Correct Answer: D
Rationale: The correct answer is D: Allow the family to view the body privately. This is important as it allows the family to have closure, grieve, and say their goodbyes in a respectful and private manner. It also promotes a sense of dignity and respect for the deceased. Choice A is incorrect as it may delay the family's grieving process. Choice B is incorrect as postmortem care should be performed after the family has had a chance to view the body. Choice C may be helpful but is not as essential as allowing the family to view the body privately.
A nurse is preparing to remove a client's urinary catheter. After performing hand hygiene, which of the following actions should the nurse take?
- A. Position the client supine.
- B. Have the client bear down during removal.
- C. Cleanse the perineal area with an antiseptic.
- D. Deflate the balloon halfway and then pull out the catheter.
Correct Answer: A
Rationale: The correct answer is A: Position the client supine. This position allows for easier access to the urinary catheter and minimizes the risk of spillage or contamination. Supine position also provides better comfort and stability for the client during the catheter removal process.
Summary of other choices:
B: Having the client bear down during removal can increase the risk of injury and discomfort.
C: Cleaning the perineal area with an antiseptic is important but should be done after removing the catheter.
D: Deflating the balloon halfway and pulling out the catheter can cause pain and discomfort for the client and may lead to trauma.
A nurse is reinforcing teaching with a client who is obese and has obstructive sleep apnea about how to decrease the number of apneic episodes he has each night. Which of the following statements should the nurse identify as an indication that the client understands the instructions?
- A. I'll use a humidifier beside my bed at night.
- B. I'll sleep better if I take a sleeping pill at night.
- C. I am going to try to lose about 50 pounds.
- D. I am going to have a glass of red wine before bedtime.
Correct Answer: C
Rationale: The correct answer is C: "I am going to try to lose about 50 pounds." This statement indicates the client's understanding of how weight loss can help reduce obstructive sleep apnea episodes in obese individuals. Excess weight can contribute to airway obstruction during sleep, leading to apneic episodes. Losing weight can alleviate this pressure on the airway, improving breathing during sleep.
A: Using a humidifier may help with dry air but does not directly address the underlying cause of obstructive sleep apnea.
B: Taking a sleeping pill can mask symptoms but does not address the root cause of the issue.
D: Consuming alcohol before bedtime can worsen sleep apnea symptoms as it relaxes the throat muscles, potentially increasing the risk of apneic episodes.
A nurse is collecting data from the daughter of an older adult client. Which of the following statements by the daughter is a priority to the nurse?
- A. My mother is unable to bathe herself.'
- B. We sit outside every afternoon.'
- C. We buy the prescriptions we can afford.'
- D. My mother seems depressed.'
Correct Answer: C
Rationale: Financial constraints affecting medication adherence pose an immediate health risk and require intervention.