Nokea
Which of the following statements about fluid replacement is accurate for a client with hyperosmolar hyperglycemic nonketotic syndrome (HHNS)?
- A. Administer 2 to 3L of IV fluid rapidly
- B. Administer 6L of IV fluid over the first 24 hours
- C. Administer a dextrose solution containing normal saline solution
- D. Administer IV fluid slowly to prevent circulatory overload and collapse
Correct Answer: D
Rationale: The correct answer is D because in HHNS, the primary goal is to gradually correct dehydration without causing fluid overload. Administering IV fluid slowly helps prevent circulatory overload and collapse. Choice A is incorrect as rapid administration can lead to fluid overload and electrolyte imbalances. Choice B is incorrect as 6L over 24 hours is excessive and can cause fluid overload. Choice C is incorrect as dextrose solution with normal saline is not the ideal fluid replacement for this condition.
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When teaching a client about insulin therapy, the nurse should instruct the client to avoid which over-the- counter preparation that can interact with insulin?
- A. Antacids
- B. Vitamins with irons
- C. Acetaminophen preparations
- D. Salicylate preparations
Correct Answer: D
Rationale: The correct answer is D: Salicylate preparations. Salicylate can potentiate the effects of insulin, leading to hypoglycemia. Therefore, the nurse should instruct the client to avoid this over-the-counter preparation when on insulin therapy. Antacids (A), vitamins with iron (B), and acetaminophen preparations (C) do not typically interact with insulin in a significant way.
Which of the following is an important preventive factor that the nurse should teach a client with rhinitis?
- A. Not to blow the nose
- B. Not to lift objects weighing more than 5-10 lb
- C. To consume small doses of ice chips
- D. To wash hands frequently
Correct Answer: D
Rationale: The correct answer is D: To wash hands frequently. This is important in rhinitis prevention as it helps reduce the spread of viruses and bacteria that can trigger or exacerbate symptoms. Washing hands removes potential allergens and irritants, reducing the risk of rhinitis flare-ups.
Choice A is incorrect as blowing the nose is necessary to clear mucus and alleviate symptoms. Choice B is irrelevant to rhinitis prevention. Choice C is not directly related to preventing rhinitis.
The nurse is interviewing a patient with a hearing deficit. Which area should the nurse use to conduct this interview?
- A. The patient’s room with the door closed
- B. The waiting area with the television turned off
- C. The patient’s room before administration of pain medication
- D. The waiting room while the occupational therapist is working on leg exercises
Correct Answer: B
Rationale: The correct answer is B because conducting the interview in a quiet environment, like the waiting area with the television turned off, reduces background noise and distractions for the patient with a hearing deficit. This allows for better communication and understanding.
A: Conducting the interview in the patient's room with the door closed may still have distractions or noise from outside the room.
C: Conducting the interview in the patient's room before administration of pain medication does not address the issue of reducing background noise for better communication.
D: Conducting the interview in the waiting room while the occupational therapist is working on leg exercises introduces additional distractions and noise, making it harder for the patient with a hearing deficit to communicate effectively.
While bathing the client, the nurse observes the client grimacing. The nurse asks if the client is experiencing pain. The client nods yes and refuses to continue the bath. The nurse removes the wash basin, makes the client comfortable, and documents the event in the client’s chart. Which of the following actions clearly demonstrates assessing?
- A. The nurse bathing the client
- B. The nurse documenting the incident
- C. The nurse asking if the client is having pain
- D. The nurse removing the wash basin
Correct Answer: C
Rationale: The correct answer is C because asking the client if they are experiencing pain is a direct action of assessment. This step involves gathering information directly from the client to understand their condition and needs. By asking the client about pain, the nurse is actively assessing the client's well-being.
A: The nurse bathing the client is not an action of assessment but rather a task related to providing care.
B: The nurse documenting the incident is important for recording the event but does not directly involve assessing the client's condition.
D: The nurse removing the wash basin is a task related to the physical care process and does not involve direct assessment of the client's well-being.
A home care nurse is assessing a client who is taking prazosin (Minipress). Which statement by the client would support the nursing diagnosis of noncompliance with medication therapy?
- A. “I don’t’d understand why I have to keep taking pills when my blood pressure is normal.”
- B. “I can’t see the numbness on the label to know how much selt is in food.”
- C. “I feel dizzy, I’ll skip my dose foe a few days.”
- D. “If I have a cold, I shouldn’t take any over-the-counter remedies without consulting my doctor.”
Correct Answer: C
Rationale: Step 1: Identify the correct answer - C: “I feel dizzy, I’ll skip my dose for a few days.”
Step 2: Explanation - This statement indicates that the client is experiencing a known side effect of prazosin (dizziness) and plans to stop the medication temporarily without consulting the healthcare provider, showing noncompliance.
Step 3: Supporting details - Skipping doses can lead to ineffective treatment and potential health risks.
Step 4: Comparison with other choices:
A: This statement shows the client questioning the need for medication but does not indicate current noncompliance.
B: This statement demonstrates difficulty reading labels but does not directly relate to medication compliance.
D: This statement shows awareness about medication interactions but does not indicate noncompliance with the prescribed medication regimen.
Summary: Choice C is correct as it directly reflects noncompliance by planning to skip doses without consulting the healthcare provider, leading to potential adverse outcomes. Choices A, B, and D do not demonstrate the