Med Surg Midterm Carl
A nurse cares for a client who is recovering from laparoscopic cholecystectomy surgery. The client reports pain in the shoulder blades. How should the nurse respond? a. "Ambulating in the hallway twice a day will help." b. "I will apply a cold compress to the painful area on your back." c. "Drinking a warm beverage can relieve this referred pain." d. "You should cough and deep breathe every hour."
a. "Ambulating in the hallway twice a day will help." The client who has undergone a laparoscopic cholecystectomy may report free air pain due to retention of carbon dioxide in the abdomen. The nurse assists the client with early ambulation to promote absorption of the carbon dioxide. Cold compresses and drinking a warm beverage would not be helpful. Coughing and deep breathing are important postoperative activities, but they are not related to discomfort from carbon dioxide.
A male client comes into the emergency department with a serum creatinine of 2.2 mg/dL and a blood urea nitrogen (BUN) of 24 mL/dL. What question should the nurse ask first when taking this client's history? a. "Have you been taking any aspirin, ibuprofen, or naproxen recently?" b. "Do you have anyone in your family with renal failure?" c. "Have you had a diet that is low in protein recently?" d. "Has a relative had a kidney transplant lately?"
a. "Have you been taking any aspirin, ibuprofen, or naproxen recently?" There are some medications that are nephrotoxic, such as the nonsteroidal anti-inflammatory drugs ibuprofen, aspirin, and naproxen. This would be a good question to initially ask the client since both the serum creatinine and BUN are elevated, indicating some renal problems. A family history of renal failure and kidney transplantation would not be part of the questioning and could cause anxiety in the client. A diet high in protein could be a factor in an increased BUN.
A nurse is discussing the home maintenance regimen with a client who has irritable bowel syndrome. Which statement indicates client understanding? a. "I'll take a walk after dinner each evening." b. "I'll have a cigarette after meals to relax." c. "I'll chew gum between meals to curb my appetite." d. "I'll eat a lot of fresh vegetables and fruits."
a. "I'll take a walk after dinner each evening." Rationale: Regular exercise can help to normalize bowel function.
A nurse assesses a client who is prescribed 5-fluorouracil (5-FU) chemotherapy intravenously for the treatment of colon cancer. Which assessment finding should alert the nurse to contact the health care provider? a. White blood cell (WBC) count of 1500/mm3 (1.5x109/L) b. Fatigue c. Nausea and diarrhea d. Mucositis and oral ulcers
a. White blood cell (WBC) count of 1500/mm3 (1.5x109/L) Common side effects of 5-FU include fatigue, leukopenia, diarrhea, mucositis and mouth ulcers, and peripheral neuropathy. However, the clients WBC count is very low (normal range is 5000 to 10,000/mm3), so the provider should be notified. He or she may want to delay chemotherapy by a day or two. Certainly the client is at high risk for infection. The other assessment findings are consistent with common side effects of 5-FU that would not need to be reported immediately.
A client presents to the clinic for a follow-up appointment after diagnostic tests show he has gastroesophageal reflux disease. Which instruction should the nurse provide? a. "Lie down and rest after each meal." b. "Avoid alcohol and caffeine." c. "Drink 16 ounces of water with each meal." d. "Eat three well-balanced meals every day."
b. "Avoid alcohol and caffeine."
A nurse is providing preoperative teaching to a client scheduled for a below the knee amputation. The client says "I hate the idea of being an invalid after they cut off my leg." Which response by the nurse would be the most therapeutic? a. "Tell me more about how you are feeling." b. "You are fortunate to have a spouse who will take care of you." c. "We will talk more about this after your surgery." d. "Focusing on using your one good leg will make your recovery easier"
a. "Tell me more about how you are feeling."
When giving report to the oncoming shift, what Interventions does the nurse include for an assigned client with emphysema? Select all that apply. a. Administer low-flow oxygen as needed b. Encourage activity alternating with rest periods c. Maintain the client in supine position as much as possible d. Teach use of postural drainage and chest physiotherapy e. Reduce fluid intake to less than 850 mL/shift
a. Administer low-flow oxygen as needed b. Encourage activity alternating with rest periods d. Teach use of postural drainage and chest physiotherapy
A client with ulcerative colitis is prescribed sulfasalazine. What statement by the client indicates to the nurse that further teaching about the medication is needed? Select one a. After taking this medication for a year, my colitis will be cured b. This medication will help control my diarrhea c. The medication will help prevent future flareups of the disease d. Sulfasalazine will decrease the inflammation in my colon
a. After taking this medication for a year, my colitis will be cured
A nurse is caring for a client who has just experienced a 90-second tonic-clonic seizure. The clients arterial blood gas values are pH 6.88, PaO2 50 mm Hg, PaCO2 60 mm Hg, and HCO3 22 mEq/L. Which action should the nurse take first? a. Apply oxygen by mask or nasal cannula. b. Administer 50 mL of 20% glucose and 20 units of regular insulin c. Apply a paper bag over the client's nose and mouth d. Administer 50 mL of sodium bicarbonate intravenously .
a. Apply oxygen by mask or nasal cannula.
A client has a tracheostomy that is 3 days old. Upon assessment, the nurse notes the clients face is puffy and the eyelids are swollen. What action by the nurse takes priority? a. Assess the clients oxygen saturation. b. Notify the Rapid Response Team. c. Oxygenate the client with a bag-valve-mask. d. Palpate the skin of the upper chest.
a. Assess the clients oxygen saturation. This client may have subcutaneous emphysema, which is air that leaks into the tissues surrounding the tracheostomy. The nurse should first assess the clients oxygen saturation and other indicators of oxygenation. If the client is stable, the nurse can palpate the skin of the upper chest to feel for the air. If the client is unstable, the nurse calls the Rapid Response Team. Using a bag-valve-mask device may or may not be appropriate for the unstable client.
A nurse is providing home care dietary instructions to a client who has been hospitalized with pancreatitis. What food does the nurse instruct the client to avoid to prevent recurrence? a. Chili b. Bagel c. Lentil soup d. Watermelon
a. Chili Rationale: The client with pancreatitis needs to avoid alcohol, coffee and tea, spicy foods, and heavy meals, which stimulate pancreatic secretions, producing attacks of pancreatitis. The client is instructed in the benefit of eating small, frequent meals that are high in protein, low in fat, and moderate to high in carbohydrates.
When developing the teaching plan for a client diagnosed with a latex allergy, what information does the nurse include? Select all that apply a. Identify the items in the home that are made from synthetic materials b. Increase in take of foods high in potassium (K), such as kiwi, bananas, avocados, and chestnuts c. Keep emergency telephone numbers readily accessible d. Before purchasing items for the home, determine if they are likely to contain latex e. Remove certain plants in the home, such as poinsettias, which can cause an allergic actions
a. Identify the items in the home that are made from synthetic materials c. Keep emergency telephone numbers readily accessible d. Before purchasing items for the home, determine if they are likely to contain latex e. Remove certain plants in the home, such as poinsettias, which can cause an allergic actions
A client has been prescribed metoprolol for hypertension. The nurse monitors client compliance carefully because of which common side effect of the medication? a. Impotence b. Mood swings c. Increased appetite d. Complete atrioventricular (AV) block
a. Impotence A common side effect of beta-adrenergic blocking agents, such as metoprolol, is impotence. Other common side effects include fatigue and weakness.Central nervous system side effects occur rarely and include mental status changes,nervousness, depression, and insomnia. Mood swings, increased appetite, and complete AV block are not reported side effects.
The nurse is assessing a client with a fractured right arm. What data is consistent with impaired venous return in the area? a. Increasing edema b. Weakened distal pulse c. Continued pain despite medication d. Pallor or blotchy cyanosis
a. Increasing edema Rationale: Impaired venous return is characterized by increasing edema. In the client with a fracture, this is most often prevented by elevating the limb. The other options identify signs of arterial damage, which can occur if the artery is contused, thrombosed, lacerated, or becomes spastic.
A scenic nurse encounters a client who has a congested cough and rhinorrhea. What does the nurse do in order to follow respiratory hygiene/cough protocol? Select all that apply. a. Offer the client disposable tissues b. Perform hand hygiene before and after contact with the client c. Wear a mask while examining the client d. Separate the client at least 3 feet away from other persons in the area e. Offer the client water to drink while waiting
a. Offer the client disposable tissues b. Perform hand hygiene before and after contact with the client d. Separate the client at least 3 feet away from other persons in the area
What nursing intervention would be most effective in preventing dehiscence in a postoperative client who had abdominal surgery? a. Prevent vomiting b. Keep surgical wound dry c. Administer prescribed antibiotics d. Help the client lose weight
a. Prevent vomiting Activities that are likely to lead to dehiscence include vomiting and coughing because they increase intra-abdominal pressure. Clients who are obese and those with poor nutrition are candidates for dehiscence. Since the client is already postoperative, encouraging weight loss at this time would not affect risk for dehiscence, and there is no indication that the client is overweight. Administering antibiotics is effective in preventing or treating infection. Antibiotic therapy alone cannot prevent dehiscence. Keeping a wound dry will promote healing and prevent infection; however, this action alone will not prevent dehiscence.
What rationale does the nurse use to explain the reason for oxygen being bubbled through a humidifier to a client receiving oxygen at 2liters/min via nasal cannula? a. Prevents drying of nasal passages b. Prevents the burning sensation of direction oxygen c. Prevents a chemical reaction between the tubing and oxygen d. Prevents contamination with environmental gases
a. Prevents drying of nasal passages
The nurse is caring for a client with renal insufficiency. In addition to the prescribed fluid restriction, the client needs strict monitoring of intake and output. What actions does the nurse include in the plan of care for this client? Select all that apply a. Provide a collection device for measuring the client's intake and output b. Discuss the plan of care and fluid restriction with the client and family c. Eliminate counting ice chips as intake because this represents such a small amount d. Encourage the family to bring favorite food items from home for the client to eat e. Document pureed foods as part of the client's liquid intake
a. Provide a collection device for measuring the client's intake and output b. Discuss the plan of care and fluid restriction with the client and family c. Eliminate counting ice chips as intake because this represents such a small amount
The nurse is caring for a client who reports abdominal and sternal pain after eating and when lying down. What recommendation does the nurse make? a. Sleep with the upper body elevated b. Eat 3 meals per day c. Increase intake of caffeine d. Lie down for 30 minutes after eating
a. Sleep with the upper body elevated
While performing the admission history of a client admitted with asthma, the nurse learns that the client has a history of hepatitis C. What precautions does the nurse implement based on transmission of the hepatitis c virus? a. Standard b. Airborne c. Droplet d. Contact
a. Standard
what does the nurse teach a client who has been prescribed isoniazid for treatment of tuberculosis to prevent development of peripheral neuropathies associated with its use? a. Supplement diet with pyridoxine (Vitamin B6) b. Avoid excessive sun exposure c. Follow a low cholesterol diet d. Obtain extra rest
a. Supplement diet with pyridoxine (Vitamin B6)
A nurse is caring for a postoperative 70-kg client who had major blood loss during surgery. Which findings by the nurse should prompt immediate action to prevent acute kidney injury? Select all that apply a. Urine output of 100 mL in 4 hours b. Urine output of 500 mL in 12 hours c. Large amount of sediment in the urine d. Amber, odorless urine e. Blood pressure of 90/60 mm Hg
a. Urine output of 100 mL in 4 hours c. Large amount of sediment in the urine e. Blood pressure of 90/60 mm Hg The low urine output, sediment, and blood pressure should be reported to the provider. Postoperatively, the nurse should measure intake and output, check the characteristics of the urine, and report sediment, hematuria, and urine output of less than 0.5 mL/kg/hour for 3 to 4 hours. A urine output of 100 mL is low, but a urine output of 500 mL in 12 hours should be within normal limits. Perfusion to the kidneys is compromised with low blood pressure. The amber odorless urine is normal
A nurse assesses a client who is recovering from a paracentesis 1 hour ago. Which assessment finding requires action by the nurse? a. Urine output via indwelling urinary catheter is 20 mL/hr b. Blood pressure increases from 110/58 to 120/62 mm Hg c. Respiratory rate decreases from 18 to 14 breaths/min d. A decrease in the client's weight by 3lbs (1.4kg)
a. Urine output via indwelling urinary catheter is 20 mL/hr Rapid removal of ascetic fluid causes decreased abdominal pressure, which can contribute to hypovolemia. This can be manifested by a decrease in urine output to below 30 mL/hr. A slight increase in systolic blood pressure is insignificant. A decrease in respiratory rate indicates that breathing has been made easier by the procedure. The nurse would expect the client's weight to drop as fluid is removed. Six kilograms is less than 3 pounds and is expected.
The nurse is caring for an older adult experiencing delirium after emergency gallbladder surgery. The client is disoriented to time, place, and person, and is attempting to get out of bed and pull out the intravenous line. The nurse receives a prescription from the provider for a vest and bilateral soft wrist restraints. What intervention is appropriate in carrying out this prescription? a. Ensure that restraints are knotted tightly b. Document alternative methods used before restraints were applied c. Perform face to face evaluation every 4 hours d. Tie the restraints to the siderails
b. Document alternative methods used before restraints were applied
The nurse is assessing a client with a mobility problem to determine an appropriate assistance device. The client's lower extremities have no paralysis, but are very weak. Upper-body strength is also reduced. The nurse should suggest which device for this client? a. Cane b. Four-wheeled walker c. Canadian or elbow extension crutch d. Lofstrand crutch
b. Four-wheeled walker The client has bilateral weakness of the lower extremities, and the proper assistive device is one that will provide bilateral support. In this case, a walker provides the most support. Additionally, a four-wheeled walker does not require the client to lift the walker as steps are taken. A cane would provide only limited support for a client with very weak lower extremities. Canadian or elbow extension crutches and Loftstand crutches require upper body strength, an identified deficiency with this client.
The nurse is assessing a client suspected of having pancreatitis. What risk factors predispose the client for pancreatitis? Select all that apply a. Hypothyroidism b. Gallstones c. Abdominal trauma d. Hypertension e. Excessive alcohol use
b. Gallstones c. Abdominal trauma e. Excessive alcohol use Pancreatitis, a chronic or acute inflammation of the pancreas, is a potentially life-threatening condition. Excessive alcohol intake and gallstones are the greatest risk factors. Abdominal trauma can potentiate inflammation. Hyperlipidemia is a risk factor for recurrent pancreatitis. Hypertension and hypothyroidism are not associated with pancreatitis.
The clinic nurse assesses a client with diabetes during a checkup. The client also has osteoarthritis (OA). The nurse notes the clients blood glucose readings have been elevated. What question by the nurse is most appropriate? a. Are you compliant with following the diabetic diet? b. Have you been taking glucosamine supplements? c. How much exercise do you really get each week? d. You're still taking your diabetic medication, right?
b. Have you been taking glucosamine supplements? All of the topics are appropriate for a client whose blood glucose readings have been higher than usual. However, since this client also has OA, and glucosamine can increase blood glucose levels, the nurse should ask about its use. The other questions all have an element of nontherapeutic communication in them. "Compliant" is a word associated with negative images, and the client may deny being "noncompliant." Asking how much exercise the client "really" gets is accusatory. Asking if the client takes his or her medications "right?" is patronizing.
What factors increase the risk for hypothermia in an older client? Select all that apply. a. Hyperthyroidism b. Hypoglycemia c. Burns d. Ability to sense cold temperatures e. Anemia
b. Hypoglycemia c. Burns d. Ability to sense cold temperatures e. Anemia
The nurse is teaching a client who is preparing for discharge from the hospital after a total hip replacement. Which statement by the client would indicate the need for further instructions? a. I cannot drive a car for probably 6 weeks b. I should not sit in one position for more than 4 hours c. I need to wear a support stocking on an unaffected leg d. I need to place a pillow between my knees when I lie down
b. I should not sit in one position for more than 4 hours Rationale: The client needs to be instructed to not sit continuously for more than 1 hour. The client should be instructed to stand, stretch, and take a few steps periodically. The client cannot drive a car for 6 weeks after surgery unless allowed to do so by a physician. A support stocking should be worn on the unaffected leg, and an Ace bandage usually is prescribed to be placed on the affected leg until there is no swelling in the legs and feet and until full activities are resumed. The legs are abducted by placing a pillow between them when the client lies down.
The nurse has explained a therapeutic diet to the client. To ensure learning occurred, the nurse should do which of the following? a. Refer client to a nutritionist b. Listen to comments from the client c. Repeat details of the diet an additional 1-2 times d. Ask another nurse to verify client understands the diet
b. Listen to comments from the client
What interventions does the nurse implement for a client who has just had surgery for a detached retina in the right eye? Select all that apply a. Encourage deep breathing and coughing b. Orient client to the environment c. Place client in prone position d. Discourage client from bending down e. Administer a stool softener
b. Orient client to the environment c. Place client in prone position d. Discourage client from bending down
When receiving intershift report, the nurse is informed about a client who is described as a drug seeker who is obsessed with even tiny changes in physical condition and is "on the light constantly" asking for more pain medication. When assessing this client's pain, what is the most appropriate question for the nurse to ask the client? a. "You cannot have more pain medication for 3 hours." b. "Why do you think the medication is not helping your pain?" c. "Help me understand how pain is affecting you right now." d. "I wish I could do more; is there anything I can get for you?"
c. "Help me understand how pain is affecting you right now."
The nurse has completed teaching a community group about burn prevention. What statement by a member group would cause the nurse the greatest concern? a. "I get my chimney swept every other year." b. "My hot water heater is set at 120 degrees." c. "Sometimes I wake up at night and smoke." d. "I use a space heater when it gets below zero."
c. "Sometimes I wake up at night and smoke." House fires are a common occurrence and often lead to serious injury or death. The nurse should be most concerned about a person who wakes up at night and smokes. The nurse needs to question this person about whether he or she gets out of bed to do so, or if this person stays in bed, which could lead to falling back asleep with a lighted cigarette. Although it is recommended to have chimneys swept every year, skipping a year does not pose as much danger as smoking in bed, particularly if the person does not burn wood frequently. Water heaters should be set below 140° F. Space heaters should be used with caution, and the nurse may want to ensure that the person does not allow it to get near clothing or bedding.
When transferring a client into a chair, a nurse notices that the pressure-relieving mattress overlay has deep imprints of the client's buttocks, heels, and scapulae. Which action should the nurse take next? a. Turn the mattress overlay to the opposite side. b. Do nothing because this is an expected occurrence. c. Apply a different pressure-relieving device. d. Reinforce the overlay with extra cushions.
c. Apply a different pressure-relieving device. Bottoming out, as evidenced by deep imprints in the mattress overlay, indicates that this device is not appropriate for this client, and a different device or strategy should be implemented to prevent pressure ulcer formation.
A client just diagnosed with human immune deficiency virus (HIV) expresses feelings of despair and does not know what to do. What is the most appropriate action by the nurse? a. Determine if a clergy member would help b. Explain legal requirements to tell sex. partners c. Assess the client for support systems d. Offer to tell the family for the client
c. Assess the client for support systems This client needs the assistance of support systems. The nurse should help the client identify them and what role they can play in supporting him or her.
The nurse reviews the laboratory reports of a client with cancer receiving chemotherapy, and notes that the platelet count is 18,000 calls/mm3. Based on this result, what does the nurse implement? Select one a. Contact precautions b. Neutropenic precautions c. Bleeding precautions d. Respiration, precautions
c. Bleeding precautions
What food does the nurse teach a client with heart failure to limit when following a 2 gram sodium (Na) diet? a. Apples b. Whole wheat bread c. Canned tomato juice d. Beef tenderloin
c. Canned tomato juice
The nurse is caring for a client being discharged following kidney transplantation. The client is ordered mofetil to prevent organ rejection. Which nursing instruction is essential regarding medication use? a. Administer medication following breakfast daily. b. Sprinkle the contents of the capsule on food. c. Contact the health care provider at first signs of an infection. d. Administer the medication with an antacid to prevent stomach upset.
c. Contact the health care provider at first signs of an infection. Mofetil is an organ rejection medication that diminishes the body's ability to identify and eliminate pathogens (immunosuppressant). Identifying symptoms of infection at an early state is helpful in treating the infection. This medication is administered on an empty stomach. Typically, capsules would not be opened dispensing medication at one time. Antacids may decrease the absorption of the medication
A client admitted to the hospital for gallbladder surgery is diagnosed as having a vitamin C deficiency. The nurse places high priority on assessing this client for which development postoperatively? a. Unusual muscle weakness b. Mental confusion c. Delayed wound healing d. Ataxia upon ambulating
c. Delayed wound healing Rationale: Protein and vitamin C are necessary for building and maintaining tissues. A deficiency of vitamin C would prolong wound healing. A vitamin C deficiency is not associated with unusual muscle weakness.
The nurse is teaching the family of a client diagnosed with leukemia about ways to prevent infection. Which instruction has the most impact? a. Eating only a plant-based diet ' b. Covering client's mouth when coughing c. Maintaining intact skin integrity d. Bathing the client daily
c. Maintaining intact skin integrity
A client has been admitted to the nursing unit with a 3-day history of severe nausea and vomiting with diarrhea. The client is experiencing fatigue, anorexia, and muscle weakness. Based on this history, which laboratory findings should the nurse expect to find? a. Calcium 11.6 mg/dL b. Sodium 144 mEq/L c. Potassium 2.9 mEq/L d. Calcium 7.4 mEq/L
c. Potassium 2.9 mEq/L Rationale: Loss of potassium caused by vomiting and diarrhea, in addition to lack of replacement intake, will lead to a risk for hypokalemia (normal range is 3.5-5.1 mEq/L). Calcium levels (normal 9-11 mg/dL) would not be elevated with vomiting. Sodium level (normal 135-145 mEq/L) will be elevated with the loss of potassium. Calcium levels (normal 9-11 mg/dL) are not reduced by vomiting and diarrhea
What should the nurse assess for in an older adult who has diminished vision and hearing? a. Sensory overload b. Cognitive impairment c. Social isolation d. Feelings of disorientation
c. Social isolation Social isolation is a concern for an older adult who has diminished hearing and vision
While the nurse is discussing a client's likely death with family members, one of the adult children asks, "We plan on taking turns being here for now, but we all want to be here at the time of mother's death. Is there any way we can tell when that time is close? " What is the nurse's best response? a. Often, people become lucid for about 15 minutes during the last hour before death. Watch for your mother to become more alert with clearer eyes, focus on faces and clear there throat. Call the others in at that time. b. I wish I could tell you that there was a way to know. It could be minutes from now or another three days. One never knows c. The arms and legs become more bluish in color and are cool to touch. Breathing becomes irregular and shallow and will change speed. Call me if you hear mucus in the throat. The pulse and blood pressure will decrease d. You can expect muscles to become rigid, with staring eyes and mouth closed. The head is pull back with neck rigidity. Don't be alarmed when you hear a death rattle in the throat
c. The arms and legs become more bluish in color and are cool to touch. Breathing becomes irregular and shallow and will change speed. Call me if you hear mucus in the throat. The pulse and blood pressure will decrease
A nurse teaches a client who is recovering from a nephrectomy secondary to kidney trauma. Which statement should the nurse include in this client's teaching? a. "Since you only have one kidney, a salt and fluid restriction is required." b. "Your therapy will include hemodialysis while you recover." c. "Medication will be prescribed to control your high blood pressure." d. "You need to avoid participating in contact sports like football."
d. "You need to avoid participating in contact sports like football." Clients with one kidney need to avoid contact sports because the kidneys are easily injured. The client will not be required to restrict salt and fluids, end up on dialysis, or have new hypertension because of the nephrectomy.
A client with fluid volume excess is treated with administration of bumetanide. After administration, the client's potassium (K) level decreases to 3.0 mEq/L, and intravenous (IV) potassium (K/ is prescribed. What factor does the nurse consider when preparing to administer the IV K replacement? a. Should be administered IV push b. Concentration should not exceed 20 mEq/L c. Ice or warm packs may be needed to reduce vein irritation d. Add K to the IV solution already infusing
d. Add K to the IV solution already infusing
What process occurs during the S phase of the cell cycle? a. Growing extra membrane b. No reproductive activity c. Actual division (mitosis) d. Doubling of DNA
d. Doubling of DNA
Which nursing instruction is most applicable to a client who is newly diagnosed with chronic pyelonephritis? a. Remain on bed rest for up to 2 weeks b. Expect to take an analgesic on a regular basis for the next 6 months c. Expect to provide a urine specimen for culturing every 2 weeks for up to 6 months d. Expect to be on an antibiotic for several weeks or even months
d. Expect to be on an antibiotic for several weeks or even months Chronic pyelonephritis is a long-term condition, often requiring antibiotic treatment for several weeks or months and close monitoring to prevent perm. kidney damage. Bed rest and analgesics may be prescribed during the acute stage, but they are usually not required long term. A urine culture is typically ordered 2 weeks after stopping antibiotics to ensure the infection has been eradicated
A nurse cares for a client with a urine specific gravity of 1.040. Which action should the nurse take? a. Obtain a urine culture and sensitivity. b. Place the client on restricted fluids. c. Assess the client's creatinine level. d. Increase the client's fluid intake.
d. Increase the client's fluid intake. Normal specific gravity for urine is 1.005 to 1.030. A high specific gravity can occur with dehydration, decreased kidney blood flow (often because of dehydration), and the presence of antidiuretic hormone. Increasing the client's fluid intake would be a beneficial intervention. Assessing the creatinine or obtaining a urine culture would not provide data necessary for the nurse to make a clinical decision.
The nurse is caring for a client who had just had an ankle-brachial index (ABI) test. The left arms BP was 160/80 mm Hg, and a palpable systolic BP on the left lower extremity was 130/60 mm Hg. How does the nurse interpret these results? a. Severe peripheral artery disease; b. Moderate peripheral artery disease; c. No apparent occlusion in the left lower extremity d. Mild peripheral artery disease
d. Mild peripheral artery disease
When caring for a client admitted with cirrhosis and ascites, what dietary measure does the nurse expect to be prescribed? a. Increased fat intake b. Restriction of 1500 calories per day c. Decreased carbohydrates d. Sodium (Na) restriction
d. Sodium (Na) restriction
A client with nephrolithiasis arrives at the clinic for a follow-up visit: The laboratory analysis of the stone that was passed a week ago indicates that the stone is composed of calcium oxalate. Based on this information, what food does the nurse advise the client to avoid? a. Pasta b. Lentils c. Lettuce d. Spinach
d. Spinach Rationale: Many kidney stones are composed of calcium oxalate. Foods that raise urinary oxalate excretion include spinach, rhubarb, strawberries, chocolate, wheat bran, nuts, beets, and tea. Pasta, lentils, and lettuce are acceptable to consume.
The nurse is caring for a client who has severe burns on the head, neck, trunk, and groin areas. Which position would be most appropriate for preventing contractures? a. High-fowlers b. Semi-fowlers c. Prone d. Supine
d. Supine
