Nokea
While monitoring the urine specific gravity of a client with a head injury, the nurse notes that the client's specific gravity is 1.004 . The most likely explanation for this finding is:
- A. The client is adequately hydrated.
- B. The client is experiencing renal failure.
- C. The client has adequate ADH secretion.
- D. The client is experiencing diabetes insipidus.
Correct Answer: D
Rationale: A low specific gravity (1.004) suggests dilute urine, common in diabetes insipidus due to impaired ADH secretion, often seen in head injuries.
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The nurse is performing an assessment on a client with pneumococcal pneumonia. Which finding would the nurse anticipate?
- A. Bronchial breath sounds in outer lung fields
- B. Decreased tactile fremitus
- C. Hacking, nonproductive cough
- D. Hyper-resonance of areas of consolidation
Correct Answer: A
Rationale: Bronchial breath sounds in outer lung fields. Consolidated lung tissue in pneumonia transmits bronchial breath sounds to outer lung fields.
A 23-year-old man comes to the AIDS clinic for treatment of large, painful, purplish-brown open areas on his right arm and back.
The nurse should instruct the client to
- A. clean the area carefully with soap and warm water every day and cover them with a sterile dressing.
- B. soak in a warm tub twice a day and rub the areas with a washcloth before covering them.
- C. shower daily using a mild antimicrobial soap from a pump dispenser and leave the lesions uncovered.
- D. clean the lesions twice a day with a diluted solution of povidone-iodine (Betadine) and leave them open to the air.
Correct Answer: A
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) correct-open Kaposi's sarcoma lesions should be cleaned and dressed daily to prevent secondary infection (2) not done because of risk of secondary skin infection (3) important to keep the skin clean to prevent secondary skin infection but should be covered due to open areas (4) treatment for herpes simplex virus abscess, not Kaposi's sarcoma
The nurse is teaching a client with a new diagnosis of hypothyroidism about levothyroxine (Synthroid). Which of the following statements by the client indicates a need for further teaching?
- A. I should take this medication on an empty stomach.
- B. I should report chest pain to my doctor.
- C. I should avoid taking this with antacids.
- D. I should stop this medication if my thyroid levels are normal.
Correct Answer: D
Rationale: Stopping levothyroxine when thyroid levels are normal is incorrect, as hypothyroidism requires lifelong replacement therapy. Options A, B, and C are correct: empty stomach dosing improves absorption, chest pain may indicate overdose, and antacids interfere with absorption.
An adult had exploratory surgery and postoperatively had an exacerbation of asthma. The client is on a rebreathing mask and seems upset and angry. What is the best nursing approach?
- A. Ask the physician for an order for lorazepam (Ativan).
- B. Spend some time with the client.
- C. Ask the family to have someone stay with the client.
- D. Apply wrist restraints.
Correct Answer: B
Rationale: Spending time with the client addresses emotional distress, calming them without medication or restraints, supporting asthma management.
An adult has experienced significant vomiting and diarrhea for the past 24 hours. Her chloride level is 90 mEq/L. What would the nurse expect to find when interpreting her sodium level?
- A. It would be high.
- B. It is impossible to predict the sodium level with this information.
- C. It would be low.
- D. It would be normal.
Correct Answer: C
Rationale: Vomiting and diarrhea cause sodium loss, likely resulting in a low sodium level, consistent with a low chloride level.