Nokea
Which of the following is a correctly stated nursing diagnosis for a client with abruptio placentae?
- A. Infection related to obstetrical trauma.
- B. Potential for fetal injury related to abruptio placentae.
- C. Potential alteration in tissue perfusion related to depletion of fibrinogen.
- D. Fluid volume deficit related to bleeding.
Correct Answer: D
Rationale: Abruptio placentae causes hemorrhage, leading to fluid volume deficit, a major nursing concern. The other options are incorrectly stated or irrelevant: infection is not typical, ‘potential’ diagnoses are not standard, and fibrinogen depletion is not the primary issue.
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Which of the following electrolytes must be maintained in a steady state for a client receiving lithium?
- A. Sodium
- B. Potassium
- C. Chloride
- D. Magnesium
Correct Answer: A
Rationale: Sodium levels must be stable in clients taking lithium, as fluctuations can affect lithium levels and toxicity risk.
The nurse is caring for an adult who has had nausea and vomiting for several days and is being admitted to the nursing care unit. The client can follow directions. IV fluids were started in the emergency department. Which action is the highest priority for the nurse at this time?
- A. Offer oral fluids every hour.
- B. Turn every two hours.
- C. Monitor urine output.
- D. Put client in a supine position.
Correct Answer: C
Rationale: Monitoring urine output is critical to assess hydration status and kidney function in a client with prolonged nausea and vomiting, as dehydration is a major risk. IV fluids address dehydration, making oral fluids less urgent, and turning or positioning are secondary.
The nurse is providing home care to an elderly woman who had a cerebrovascular accident (CVA) and has right-sided hemiplegia. She is living with her daughter. Which observation indicates that the family needs more instruction?
- A. The client's arms and legs are exercised every day.
- B. The daughter gets her mother out of bed several times a day.
- C. The client is given a shower every other day.
- D. The daughter puts the chair on the right side of the bed when getting her mother out of bed.
Correct Answer: D
Rationale: Placing the chair on the right (paralyzed) side hinders safe transfers; it should be on the unaffected left side, indicating a need for further instruction.
A 30-year-old woman is receiving levothyroxine sodium (Synthroid) 0.1 mg PO daily.
Which of the following findings would indicate to the nurse that the client is getting favorable results from the medication?
- A. Decreased blood pressure.
- B. Increased urine output.
- C. Decreased pulse rate.
- D. Increased respiratory rate.
Correct Answer: B
Rationale: Strategy: Determine how each answer choice relates to hypothyroidism. (1) characteristic of hypothyroidism, would indicate that medication is not working (2) correct-medication increases metabolic processes of body, including glomerular filtration, edema will decrease as water is excreted (3) characteristic of hypothyroidism, would indicate that medication is not working (4) respiratory rate may or may not be affected by medication
The nurse observes a staff member not following the plan of care for a client with an antisocial personality disorder. The nurse should:
- A. confront the staff member immediately and say, 'You know that is not the treatment plan.'
- B. write an incident report to create a paper trail of the staff member's failure to follow the planned program.
- C. ask the staff member to talk in private, and reinforce how antisocial clients try to divide staff.
- D. bring up the incident during the weekly conference so that this staff member is not assigned to work with antisocial persons again.
Correct Answer: C
Rationale: It is essential that the treatment program be followed exactly for clients with antisocial personality disorder because they are very manipulative and attempt to divide staff. However, confronting the staff member in front of the client enhances the division of staff.