Nokea
A nurse is planning care for a client who sustained a major burn over 20% of the body.
Which of the following interventions should the nurse include to support the client's nutritional requirements?
- A. Keep a calorie count for foods and beverages
- B. Provide a high-calorie, high-protein diet
- C. Encourage a low-fat diet to prevent digestive issues
- D. Restrict oral intake and provide IV fluids only
Correct Answer: B
Rationale: The correct answer is B: Provide a high-calorie, high-protein diet. This intervention supports the client's nutritional requirements by ensuring they receive adequate energy and protein for healing and overall health. High-calorie intake can prevent malnutrition, while high-protein intake supports tissue repair and immune function. Keeping a calorie count (A) is helpful but not as crucial as ensuring the client receives enough calories and protein. Encouraging a low-fat diet (C) is not the priority when aiming to meet nutritional requirements. Restricting oral intake (D) and providing IV fluids only can lead to malnutrition and should be avoided.
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A nurse is caring for a client who is in active labor and note the FHR baseline has been 100/min for the past 15 min. The nurse should identify which of the following conditions as a possible cause of fetal bradycardia?
- A. Maternal fever
- B. Fetal anemia
- C. Maternal hypoglycemia
- D. Chorioamnionitis
Correct Answer: B
Rationale: The correct answer is B: Fetal anemia. Fetal bradycardia (baseline <110/min) can be caused by inadequate oxygen delivery to the fetus, such as in fetal anemia. Anemia decreases the blood's ability to carry oxygen, leading to fetal distress. Maternal fever (A) can increase the fetal heart rate, not decrease it. Maternal hypoglycemia (C) can cause fetal distress, but typically presents with fetal tachycardia. Chorioamnionitis (D) can cause maternal fever and tachycardia, but is less likely to directly affect the fetal heart rate. Other choices are not provided.
A nurse is assessing a 5-year-old child who has diabetes insipidus and is receiving desmopressin.
Which finding should the nurse identify as an indication that the medication is effective?
- A. Heart rate 140/min
- B. Capillary refill 3 seconds
- C. Cessation of nocturnal enuresis
- D. Absence of hypoglycemic episodes
Correct Answer: C
Rationale: The correct answer is C: Cessation of nocturnal enuresis. This indicates the medication is effective because it shows improvement in the condition being treated, which in this case is nocturnal enuresis. Nocturnal enuresis is the involuntary passage of urine during sleep and it can be a result of various factors such as hormonal imbalance or bladder control issues. Therefore, if the medication is effective, it should lead to the cessation of this symptom.
Heart rate (A) and capillary refill (B) are not necessarily indicators of the effectiveness of the medication in treating nocturnal enuresis. Absence of hypoglycemic episodes (D) is more related to diabetes management rather than nocturnal enuresis.
A nurse is caring for a client
Nurses: Notes
0800:
A client who has bipolar disorder is admitted to the inpatient psychiatric unit. During the
morning assessment, the client reports blurred vision and an increase in urine output. it's noted
that the client is having clonic jerking of upper extremities: Provider notified and laboratory tests
ordered. Skin is warm and dry without rash.
Complete the following sentence by using the list of options.
The nurse understands that the patient has likely developed lithium toxicity and will be monitored for-------
- A. blood glucose levels
- B. seizure activity
- C. symptoms of infection
- D. temperature over 39.4° C(103\ F)"
Correct Answer: B
Rationale: The correct answer is B: seizure activity. Lithium toxicity can lead to neurological symptoms including seizures. Monitoring for seizure activity is crucial to prevent serious complications. Blood glucose levels (A) are not typically affected by lithium toxicity. Symptoms of infection (C) are unrelated to lithium toxicity. Monitoring temperature (D) is important but not specific to lithium toxicity.
A nurse is preparing a client for transfer to a long-term care rehabilitation facility following a below-the-knee amputation.
Which action should the nurse take to protect the client's confidentiality?
- A. Provide a verbal report of the client's condition to the paramedic performing the transfer
- B. Ensure that the client's medical records are securely transferred with the client to the new facility
- C. Give the client a copy of their medical records to take with them
- D. Share the client's condition only with the necessary healthcare providers at the rehabilitation facility
- E. Use a secure and private communication method to discuss the client's condition with the receiving facility
Correct Answer: E
Rationale: The correct answer is E: Use a secure and private communication method to discuss the client's condition with the receiving facility. This is the best action to protect the client's confidentiality because it ensures that sensitive information is shared in a confidential and secure manner, preventing unauthorized access. Verbal reports (choice A) can be overheard, risking confidentiality. While ensuring medical records are transferred securely (choice B) is important, discussing the client's condition directly with the necessary healthcare providers (choice D) is more immediate and can prevent unnecessary exposure of sensitive information. Giving the client a copy of their medical records (choice C) can compromise confidentiality if misplaced.
A nurse is caring for a client who has end-stage kidney disease. The client's adult child asks the nurse about becoming a living kidney donor for her father.
Which of the following conditions in the child's medical history should the nurse identify as a contraindication to the procedure?
- A. Hypertension
- B. Primary glaucoma
- C. History of appendectomy
- D. Iron deficiency anemia
Correct Answer: A
Rationale: The correct answer is A: Hypertension. Hypertension is a contraindication to certain procedures due to the risk of complications such as increased bleeding or cardiovascular events. Primary glaucoma, history of appendectomy, and iron deficiency anemia are not contraindications for the procedure mentioned. Glaucoma and appendectomy are unrelated to the procedure, while iron deficiency anemia may not directly impact the safety of the procedure.