Nokea
Which of these types of fluid output is not typically measured?
- A. chest tube drainage
- B. emesis
- C. evaporative water from the respiratory tract
- D. urine
Correct Answer: C
Rationale: Evaporative water from respiration is a form of insensible loss and is typically not measured.
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Which of the following individuals may legally give informed consent?
- A. an 86-year-old male with advanced Alzheimer's disease
- B. a 14-year-old girl needing an appendectomy who is not an emancipated minor
- C. a 72-year-old female scheduled for a heart transplant
- D. a 6-month-old baby needing bowel surgery
Correct Answer: C
Rationale: Only competent adults can legally give informed consent. The 72-year-old female is presumed competent unless stated otherwise. An individual with advanced Alzheimer's lacks decision-making capacity, a non-emancipated minor cannot consent, and infants are legally incapable of consenting; their guardians must provide consent.
Pressure ulcers usually occur:
- A. When clients are left in one position in bed for extended periods of time
- B. When clients are underweight
- C. When clients are overweight
- D. Only in underweight and overweight clients
Correct Answer: A
Rationale: Pressure ulcers occur over bony prominences due to decreased circulation from prolonged immobility, not specifically related to body weight.
The nurse is inserting a urinary catheter in the client with urinary retention. During balloon inflation, the client reports pain. What is the nurse's best action?
- A. Withdraw the sterile water from the balloon and advance the catheter further.
- B. Continue inflating the balloon as this finding is expected during catheter insertion.
- C. Remove the catheter and reattempt insertion with a smaller urinary catheter.
- D. Reposition the catheter by rotating it slightly and continue to inflate the balloon.
Correct Answer: A
Rationale: A: Pain suggests the catheter is in the urethra, not the bladder; advancing after deflating corrects placement. B: Pain is abnormal and risks damage. C: Removal is unnecessary if advancement works. D: Rotating a partially inflated balloon could harm the urethra.
For safety, the nurse should ask the client to:
- A. drink 1000 cc prior to the procedure to affect fluid loss.
- B. eat foods low in fat.
- C. empty his bladder prior to the procedure.
- D. assume the prone position.
Correct Answer: C
Rationale: When performing a paracentesis, the client must be sitting up to allow the fluid to settle to the lower abdomen. To prevent trauma to the bladder while inserting a needle to aspirate the fluid, the bladder must be empty.
Mrs. Peterson complains of difficulty falling asleep, awakening earlier than desired, and not feeling rested. She attributes these problems to leg pain that is secondary to her arthritis. What is the most appropriate nursing diagnosis for her?
- A. Sleep Pattern Disturbances (related to arthritis)
- B. Fatigue (related to leg pain)
- C. Knowledge Deficit (regarding sleep hygiene measures)
- D. Sleep Pattern Disturbances (related to chronic leg pain)
Correct Answer: D
Rationale: The client's sleep pattern is directly disturbed by the chronic leg pain, which is secondary to the arthritis. This nursing diagnosis is the appropriate one to directly deal with comfort measures and the like.