Nokea
Which of the following would be considered a sensible type of fluid loss?
- A. sweat
- B. respiratory excretions
- C. vomit
- D. water loss in feces
Correct Answer: A
Rationale: Sensible fluid loss is measurable, such as sweat or urine. Respiratory excretions, vomit, and fecal water loss are insensible (not easily measured).
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The charge nurse overhears the patient care assistant speaking harshly to the client with dementia. The charge nurse should:
- A. Change the nursing assistant's assignment
- B. Explore the interaction with the nursing assistant
- C. Discuss the matter with the client's family
- D. Initiate a group session with the nursing assistant
Correct Answer: B
Rationale: Exploring the interaction addresses the behavior appropriately.
The nurse is administering terbutaline (Brethine) to a client in labor. Prior to administration of the medication, the nurse assesses the client’s pulse to be 144. The nurse’s priority action should be to
- A. withhold the medication.
- B. decrease the dose by half.
- C. administer the medication.
- D. wait 15 minutes, then recheck the rate.
Correct Answer: A
Rationale: maternal tachycardia is a side effect of Brethine; other maternal side effects include nervousness, tremors, headache, and possible pulmonary edema; fetal side effects include tachycardia and hypoglycemia; Brethine is usually preferred over ritodrine (Yutopar) because it has minimal effects on blood pressure
A client with heart failure has a left ventricular ejection fraction of 38%. When educating the client about managing the condition, which of the following advice should the nurse include? Select all that apply.
- A. The client should take frequent rest periods.
- B. The client should avoid strenuous activities.
- C. The client should stop all exercises.
- D. The client should stop smoking.
- E. The client should limit alcohol intake to 2 to 3 drinks daily.
Correct Answer: A,B,D
Rationale: Rest periods (A), avoiding strenuous activities (B), and stopping smoking (D) manage heart failure. All exercise (C) is not stopped; moderate activity is encouraged. Alcohol should be minimal, not 2-3 drinks (E).
A client with a tracheostomy is exhibiting difficulty breathing, and respirations are increasingly noisy. Secretions are very thick. Which of the following initial interventions is most indicated?
- A. Increase humidification, and suction the tracheostomy tube.
- B. Notify the physician.
- C. Sit the client upright, and encourage the client to breathe deeply and cough.
- D. Gently irrigate and suction the tracheostomy tube.
Correct Answer: A
Rationale: Thick secretions causing noisy respirations and breathing difficulty indicate the need for increased humidification to thin secretions and suctioning to clear the tracheostomy tube (A). Notifying the physician (B) or encouraging coughing (C) is secondary, and irrigation (D) is not typically the initial step.
A client is receiving oxygen per nasal cannula at 3 L/minute. Which of the following is the approximate inspired oxygen concentration (FiO2)?
- A. 60%
- B. 50%
- C. 40-42%
- D. 28-32%
Correct Answer: D
Rationale: Nasal cannula at 3 L/min delivers approximately 28-32% FiO2 (D), as each liter adds about 4% above room air (21%).