Nokea
While assessing a client with fluid volume deficit, which of the following findings should the nurse expect?
- A. Bradycardia
- B. Increased skin turgor
- C. Dry mucous membranes
- D. Hypertension
Correct Answer: C
Rationale: Dry mucous membranes are a classic clinical manifestation of fluid volume deficit. Dehydration leads to reduced fluid intake or excessive fluid loss, resulting in decreased moisture in the mucous membranes. Bradycardia, increased skin turgor, and hypertension are not typically associated with fluid volume deficit. Bradycardia is more commonly seen in conditions like hypothyroidism or increased intracranial pressure. Increased skin turgor is a sign of dehydration, and hypertension is not a typical finding in fluid volume deficit.
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Studies have shown that about 40% of patients fall out of bed despite the use of side rails; this has led to which of the following conclusions?
- A. Side rails are ineffective
- B. Side rails should not be used
- C. Side rails are a deterrent that prevent a patient from falling out of bed
- D. Side rails are a reminder to a patient not to get out of bed
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Which is the correct procedure for collecting a sputum specimen for culture and sensitivity testing?
- A. Have the patient place the specimen in a container and enclose the container in a plastic bag
- B. Have the patient expectorate the sputum while the nurse holds the container
- C. Have the patient expectorate the sputum into a sterile container
- D. Offer the patient an antiseptic mouthwash just before he expectorates the sputum
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Your assigned client has encephalitis, and there are other cases in the community. In a team meeting regarding your client and prevention of other cases of encephalitis, the nurse supervisor talks about breaking the chain of infection at the second link: the reservoir. You realize the nurse supervisor is talking about which of the following things?
- A. an area for the storage and filtering of water
- B. a place where the microorganism enters the body
- C. the place where the microorganism naturally lives
- D. the microorganism itself
Correct Answer: C
Rationale: Breaking the infection chain at the reservoir means targeting where the microorganism naturally lives like mosquitoes for encephalitis. This differs from the pathogen itself, entry portals, or unrelated water storage. Controlling reservoirs, such as vector elimination, stops transmission early, a vital nursing strategy in outbreak prevention discussed in team settings.
A nurse is caring for a client who has a new prescription for a low-cholesterol diet. Which of the following foods should the nurse recommend?
- A. Eggs
- B. Cheese
- C. Chicken breast
- D. Butter
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
When assessing the urinary output of a client who has had extracorporeal lithotripsy, the nurse can expect to find:
- A. Cherry-red urine that gradually becomes clearer
- B. Orange-tinged urine containing particles of calculi
- C. Dark red urine that becomes cloudy in appearance
- D. Dark, smoky-colored urine with high specific gravity
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.