Which of the following statements accurately reflects a rule of thumb upon which the nurse may rely in assessing the patient’s fluid balance? a) Minimal intake of 1.5 liters per day If food and fluids are withheld, IV fluids (3L/day) are usually prescribed. b) Minimal urine output of 50 milliliters per hour Minimal urine output may be less than 50 mL/hr. c) Minimal urine output of 10 milliliters per hour Minimal urine output must exceed 10 mL/hr. d) Minimal intake of 2 liters per day Minimal intake, as a rule of thumb, is less than 2 liters per day.

Which of the following statements accurately reflects a rule of
thumb upon which the nurse may rely in assessing the patient’s fluid
balance?
a) Minimal intake of 1.5 liters per day
If food and fluids are withheld, IV fluids (3L/day) are usually
prescribed.
b) Minimal urine output of 50 milliliters per hour
Minimal urine output may be less than 50 mL/hr.
c) Minimal urine output of 10 milliliters per hour
Minimal urine output must exceed 10 mL/hr.
d) Minimal intake of 2 liters per day
Minimal intake, as a rule of thumb, is less than 2 liters per day.
by

1 Answer

Answer :

a) Minimal intake of 1.5 liters per day
If food and fluids are withheld, IV fluids (3L/day) are usually
prescribed.
by

Related questions

When the nurse notes that the post cardiac surgery patient demonstrates low urine output (< 25 ml/hr) with high specific gravity (> 1.025), the nurse suspects: a) Inadequate fluid volume Urine output of less than 25 ml/hr may indicate a decrease in cardiac output. A high specific gravity indicates increased concentration of solutes in the urine which occurs with inadequate fluid volume. b) Normal glomerular filtration Indices of normal glomerular filtration are output of 25 ml or greater per hour and specific gravity between 1.010 and 1.025. c) Overhydration Overhydration is manifested by high urine output with low specific gravity. d) Anuria The anuric patient does not produce urine.

Description : When the nurse notes that the post cardiac surgery patient demonstrates low urine output (< 25 ml/hr) with high specific gravity (> 1.025), the nurse suspects: a) Inadequate fluid volume Urine ... by high urine output with low specific gravity. d) Anuria The anuric patient does not produce urine.

Last Answer : a) Inadequate fluid volume Urine output of less than 25 ml/hr may indicate a decrease in cardiac output. A high specific gravity indicates increased concentration of solutes in the urine which occurs with inadequate fluid volume.

In assessing the appropriateness of removing a suprapubic catheter, the nurse recognizes that the patient’s residual urine must be less than which of the following amounts on two separate occasions (morning and evening)? a) 100 cc If the patient complains of discomfort or pain, however, the suprapubic catheter is usually left in place until the patient can void successfully.

Description : In assessing the appropriateness of removing a suprapubic catheter, the nurse recognizes that the patient's residual urine must be less than which of the following amounts on two separate occasions ... urine that is greater than 100 cc indicates that the suprapubic catheter cannot be discontinued.

Last Answer : a) 100 cc If the patient complains of discomfort or pain, however, the suprapubic catheter is usually left in place until the patient can void successfully.

When the nurse observes the patient’s urine to be orange, she further assesses the patient for a) intake of medication such as phenytoin (Dilantin). Urine that is orange may be caused by intake of Dilantin or other medications. Orange to amber colored urine may also indicate concentrated urine due to dehydration or fever.

Description : When the nurse observes the patient's urine to be orange, she further assesses the patient for a) intake of medication such as phenytoin (Dilantin). Urine that is orange may be caused by intake ... white urine may indicate infection, pyruria, or in the female patient, the use of vaginal creams.

Last Answer : a) intake of medication such as phenytoin (Dilantin). Urine that is orange may be caused by intake of Dilantin or other medications. Orange to amber colored urine may also indicate concentrated urine due to dehydration or fever.

For individuals known to be dying by virtue of age and/or diagnoses, which of the following signs indicate approaching death: a) Increased restlessness As the oxygen supply to the brain decreases, the patient may become restless. b) Increased wakefulness As the body weakens, the patient will sleep more and begin to detach from the environment. c) Increased eating For many patients, refusal of food is an indication that they are ready to die. d) Increased urinary output Based upon decreased intake, urinary output generally decreases in amount and frequency.

Description : For individuals known to be dying by virtue of age and/or diagnoses, which of the following signs indicate approaching death: a) Increased restlessness As the oxygen supply to the ... Increased urinary output Based upon decreased intake, urinary output generally decreases in amount and frequency.

Last Answer : a) Increased restlessness As the oxygen supply to the brain decreases, the patient may become restless.

Which of the following observations regarding ulcer formation on the patient’s lower extremity indicate to the nurse that the ulcer is a result of venous insufficiency? a) The border of the ulcer is irregular. The border of an ulcer caused by arterial insufficiency is circular. b) The ulcer is very painful to the patient, even though superficial. Superficial venous insufficiency ulcers cause minimal pain. c) The ulcer base is pale to black. The base of a venous insufficiency ulcer shows beefy red to yellow fibrinous color. d) The ulcer is deep, involving the joint space. Venous insufficiency ulcers are usually superficial.

Description : Which of the following observations regarding ulcer formation on the patient's lower extremity indicate to the nurse that the ulcer is a result of venous insufficiency? a) The border of the ... d) The ulcer is deep, involving the joint space. Venous insufficiency ulcers are usually superficial.

Last Answer : a) The border of the ulcer is irregular. The border of an ulcer caused by arterial insufficiency is circular.

Which of the following solutions should the nurse anticipate for fluid replacement in the male patient? a) Lactated Ringer’s solution Replacement fluids may include isotonic electrolyte solutions and blood component therapy.

Description : Which of the following solutions should the nurse anticipate for fluid replacement in the male patient? a) Lactated Ringer's solution Replacement fluids may include isotonic electrolyte solutions and ... only to treat severe symptomatic hyponatremia and should be used only in intensive care units.

Last Answer : a) Lactated Ringer’s solution Replacement fluids may include isotonic electrolyte solutions and blood component therapy.

Regarding tolerance and addiction, the nurse understands that a) although patients may need increasing levels of opioids, they are not addicted. Physical tolerance usually occurs in the absence of addiction. b) tolerance to opioids is uncommon. Tolerance to opioids is common. c) addiction to opioids commonly develops. Addiction to opioids is rare. d) the nurse must be primarily concerned about development of addiction by the patient in pain. Addiction is rare and should never be the primary concern for a patient in pain.

Description : Regarding tolerance and addiction, the nurse understands that a) although patients may need increasing levels of opioids, they are not addicted. Physical tolerance usually occurs in the absence of addiction. b ... pain. Addiction is rare and should never be the primary concern for a patient in pain.

Last Answer : a) although patients may need increasing levels of opioids, they are not addicted. Physical tolerance usually occurs in the absence of addiction.

Which of the following statements reflects the nursing management of the patient with West Nile Virus infection? There is no treatment for West Nile Virus infection. Patients are supported by fluid replacement, airway management, and standard nursing care support during the time that the patient has meningitis symptoms. a) The incubation period is three to five days. The incubation period (from mosquito bite until onset of symptoms) is between 5–15 days.

Description : Which of the following statements reflects the nursing management of the patient with West Nile Virus infection? There is no treatment for West Nile Virus infection. Patients are supported by fluid replacement ... the virus to animals and humans. There is no human-to-human transmission of virus.

Last Answer : a) The incubation period is three to five days. The incubation period (from mosquito bite until onset of symptoms) is between 5–15 days.

Which of the following statements reflects nursing care of the woman with mild to moderate ovarian hyperstimulation syndrome (OHSS)? a) Advise the patient to decrease her activity, monitor her urine output and to return for frequent office visits. Management in mild and moderate cases of OHSS consists of decreased activity, monitoring of urine output and frequent office visits as designated by the reproductive endocrinologist.

Description : Which of the following statements reflects nursing care of the woman with mild to moderate ovarian hyperstimulation syndrome (OHSS)? a) Advise the patient to decrease her activity, monitor ... for immediate hospitalization. The patient with severe OHSS is hospitalized for monitoring and treatment.

Last Answer : a) Advise the patient to decrease her activity, monitor her urine output and to return for frequent office visits. Management in mild and moderate cases of OHSS consists of decreased activity, monitoring of urine output and frequent office visits as designated by the reproductive endocrinologist.

Three medications referred to as the ‘ABC drugs’ are currently the main pharmacological therapy for multiple sclerosis. Which of the following statements reflects information to be included in patient teaching? a) Flu-like symptoms can be controlled with nonsteroidal antiinflammatory drugs (NSAIDs) and usually resolve after a few months of therapy. Seventy-five percent of patients taking one of the interferons experience flu-like symptoms that can be controlled with NSAIDS and usually resolve after a few months of therapy.

Description : Three medications referred to as the ABC drugs' are currently the main pharmacological therapy for multiple sclerosis. Which of the following statements reflects information to be included in patient ... on an empty stomach. Glatiramer acetate is administed by intramuscular injection once a week.

Last Answer : a) Flu-like symptoms can be controlled with nonsteroidal antiinflammatory drugs (NSAIDs) and usually resolve after a few months of therapy. Seventy-five percent of patients taking one of the ... symptoms that can be controlled with NSAIDS and usually resolve after a few months of therapy.

The nurse recognizes which of the following signs as typical of the patient in shock? a) Rapid, weak, thready pulse Pulse increases as the body tries to compensate. b) Flushed face Pallor is an indicator of shock. c) Warm, dry skin Skin is generally cool and moist in shock. d) Increased urine output Usually, a low blood pressure and concentrated urine are observed in the patient in shock.

Description : The nurse recognizes which of the following signs as typical of the patient in shock? a) Rapid, weak, thready pulse Pulse increases as the body tries to compensate. b) Flushed face Pallor is ... urine output Usually, a low blood pressure and concentrated urine are observed in the patient in shock.

Last Answer : a) Rapid, weak, thready pulse Pulse increases as the body tries to compensate.

When measuring the blood pressure in each of the patient’s arms, the nurse recognizes that in the normal adult, the pressures a) differ no more than 5 mm Hg between arm pressures. Normally, in the absence of disease of the vasculature, there is a difference of no more than 5 mm Hg between arm pressures. b) must be equal in both arms. The pressures in each arm do not have to be equal in order to be considered normal. c) may vary 10 mm Hg or more between arms. Pressures that vary more than 10 mm Hg between arms indicate an abnormal finding. d) may vary, with the higher pressure found in the left arm. The left arm pressure is not anticipated to be higher than the right as a normal anatomical variant.

Description : When measuring the blood pressure in each of the patient's arms, the nurse recognizes that in the normal adult, the pressures a) differ no more than 5 mm Hg between arm pressures. Normally, in ... . The left arm pressure is not anticipated to be higher than the right as a normal anatomical variant.

Last Answer : a) differ no more than 5 mm Hg between arm pressures. Normally, in the absence of disease of the vasculature, there is a difference of no more than 5 mm Hg between arm pressures.

Which of the phases of a migraine headache usually lasts less than an hour? a) Aura The aura phase occurs in about 20% of patients who have migraines and may be characterized by focal neurological symptoms.

Description : Which of the phases of a migraine headache usually lasts less than an hour? a) Aura The aura phase occurs in about 20% of patients who have migraines and may be characterized by focal neurological ... to 72 hours. d) Recovery During the post-headache phase, patients may sleep for extended periods.

Last Answer : a) Aura The aura phase occurs in about 20% of patients who have migraines and may be characterized by focal neurological symptoms.

Which of the following statements are true of a patient with hyperglycemia and hyponatremia? A. The sodium concentration must be corrected by 5 mEq. per 100 mg. per 100 ml. elevation in blood glucose. B. With normal renal function, this patient is likely to be volume overloaded. C. Proper fluid therapy would be unlikely to include potassium administration. D. Insulin administration will increase the potassium content of cells. E. Early in treatment adequate urine output is a reliable measure of adequate volume resuscitation.

Description : Which of the following statements are true of a patient with hyperglycemia and hyponatremia? A. The sodium concentration must be corrected by 5 mEq. per 100 mg. per 100 ml. elevation in blood ... . E. Early in treatment adequate urine output is a reliable measure of adequate volume resuscitation.

Last Answer : Answer: D DISCUSSION: Each 100-mg. per 100 ml. elevation in blood glucose causes a fall in serum sodium concentration of approximately 2 mEq. per liter. Excess serum glucose ... correction of the patient's associated acidosis produce movement of potassium ions into the intracellular compartment

The charge nurse reported to the chief nurse that the Demerol 50 cc vial inventory has been incorrect for the last 24 hours. The most appropriate action of the narcotic nurse is: A. Log every injection of Demerol B. Make fraction dosage like 0.5 ml as 1 ml C. Demerol inventory must be checked every endorsement by the narcotic nurse D. Review endorsement of clients who received Demerol within the last 24 hours

Description : The charge nurse reported to the chief nurse that the Demerol 50 cc vial inventory has been incorrect for the last 24 hours. The most appropriate action of the narcotic nurse is: A. Log ... by the narcotic nurse D. Review endorsement of clients who received Demerol within the last 24 hours

Last Answer : D. Review endorsement of clients who received Demerol within the last 24 hours

The term used to describe total urine output of less than 400 mL in 24 hours is a) oliguria. Oliguria is associated with acute and chronic renal failure.

Description : The term used to describe total urine output of less than 400 mL in 24 hours is a) oliguria. Oliguria is associated with acute and chronic renal failure. b) anuria. Anuria is used to ... Nocturia refers to awakening at night to urinate. d) dysuria. Dysuria refers to painful or difficult urination.

Last Answer : a) oliguria. Oliguria is associated with acute and chronic renal failure.

When fluid intake is normal, the specific gravity of urine should be a) 1.010-1.025. Urine specific gravity is a measurement of the kidney’s ability to concentrate urine.

Description : When fluid intake is normal, the specific gravity of urine should be a) 1.010-1.025. Urine specific gravity is a measurement of the kidney's ability to concentrate urine. b) 1.000. The ... intake. d) greater than 1.025. A urine specific gravity greater than 1.025 may indicate overhydration.

Last Answer : a) 1.010-1.025. Urine specific gravity is a measurement of the kidney’s ability to concentrate urine.

A Glasgow Coma Scale (GCS) score of 7 or less is generally interpreted as a) coma. The Glasgow Coma Scale (GCS) is a tool for assessing a patient’s response to stimuli. A score of 7 or less is generally interpreted as coma.

Description : A Glasgow Coma Scale (GCS) score of 7 or less is generally interpreted as a) coma. The Glasgow Coma Scale (GCS) is a tool for assessing a patient's response to stimuli. A score of 7 or ... 3 is interpreted as least responsive. d) most responsive. A GCS score of 15 is interpreted as most responsive.

Last Answer : a) coma. The Glasgow Coma Scale (GCS) is a tool for assessing a patient’s response to stimuli. A score of 7 or less is generally interpreted as coma.

For which of the following medications must the nurse contact the pharmacist in consultation when the patient receives all oral medications by feeding tube? a) Enteric-coated tablets Enteric-coated tablets are meant to be digested in the intestinal tract and may be destroyed by stomach acids. A change of form of medication is required by patients with tube feedings.

Description : For which of the following medications must the nurse contact the pharmacist in consultation when the patient receives all oral medications by feeding tube? a) Enteric-coated tablets Enteric-coated ... make an opening in the capsule and squeeze out contents for administration by feeding tube.

Last Answer : a) Enteric-coated tablets Enteric-coated tablets are meant to be digested in the intestinal tract and may be destroyed by stomach acids. A change of form of medication is required by patients with tube feedings.

The nurse teaches the patient with a high risk for osteoporosis about risk-lowering strategies including which of the following statements? a) Walk or perform weight-bearing exercises out of doors. Risk-lowering strategies for osteoporosis include walking or exercising out of doors, performing a regular weight-bearing exercise regimen, increasing dietary calcium and vitamin D intake, smoking cessation, and consuming alcohol and caffeine consumption in moderation.

Description : The nurse teaches the patient with a high risk for osteoporosis about risk-lowering strategies including which of the following statements? a) Walk or perform weight-bearing exercises out ... alcohol and caffeine consumption in moderation, and performing a regular weight-bearing exercise regimen.

Last Answer : a) Walk or perform weight-bearing exercises out of doors. Risk-lowering strategies for osteoporosis include walking or exercising out of doors, performing a regular weight-bearing exercise ... and vitamin D intake, smoking cessation, and consuming alcohol and caffeine consumption in moderation.

The nurse recognizes which of the following statements as accurately reflecting a risk factor for breast cancer? a) Mother affected by cancer before 60 years of age Risk for breast cancer increases twofold if first-degree female relatives (sister, mother, or daughter) had breast cancer.

Description : The nurse recognizes which of the following statements as accurately reflecting a risk factor for breast cancer? a) Mother affected by cancer before 60 years of age Risk for breast cancer increases ... in women who consume even one drink daily and doubles among women drinking three drinks daily.

Last Answer : a) Mother affected by cancer before 60 years of age Risk for breast cancer increases twofold if first-degree female relatives (sister, mother, or daughter) had breast cancer.

When assessing the older adult, the nurse anticipates increase in which of the follow components of respiratory status? a) Residual lung volume As a result, patient experience fatigue and breathlessness with sustained activity. b) Vital capacity The nurse anticipates decreased vital capacity. c) Gas exchange and diffusing capacity The nurse anticipates decreased gas exchange and diffusing capacity resulting in impaired healing of tissues due to decreased oxygenation. d) Cough efficiency The nurse anticipates difficulty coughing up secretions due to decreased cough efficiency.

Description : When assessing the older adult, the nurse anticipates increase in which of the follow components of respiratory status? a) Residual lung volume As a result, patient experience fatigue ... ) Cough efficiency The nurse anticipates difficulty coughing up secretions due to decreased cough efficiency.

Last Answer : a) Residual lung volume As a result, patient experience fatigue and breathlessness with sustained activity.

When performing endotracheal suctioning, the nurse applies suctioning while withdrawing and gently rotating the catheter 360 degrees for which of the following time periods? a) 10-15 seconds In general, the nurse should apply suction no longer than 10-15 seconds because hypoxia and dysrhythmias may develop, leading to cardiac arrest. b) 30-35 seconds Applying suction for 30-35 seconds is hazardous and may result in the patient’s developing hypoxia, which can lead to dysrhythmias and, ultimately, cardiac arrest.

Description : When performing endotracheal suctioning, the nurse applies suctioning while withdrawing and gently rotating the catheter 360 degrees for which of the following time periods? a) 10-15 seconds In general ... suction for 0-5 seconds would provide too little time for effective suctioning of secretions.

Last Answer : a) 10-15 seconds In general, the nurse should apply suction no longer than 10-15 seconds because hypoxia and dysrhythmias may develop, leading to cardiac arrest.

The nurse teaches the patient with gastroesophageal reflux disease (GERD) which of the following measures to manage his disease? a) Avoid eating or drinking 2 hours before bedtime. The patient should not recline with a full stomach. b) Minimize intake of caffeine, ****, milk, and foods containing peppermint and spearmint. The patient should be instructed to avoid the listed foods and food components. c) Elevate the foot of the bed on 6- to 8-inch blocks The patient should be instructed to elevate the head of the bed on 6- to 8-inch blocks. d) Eat a low carbohydrate diet The patient is instructed to eat a low-fat diet

Description : The nurse teaches the patient with gastroesophageal reflux disease (GERD) which of the following measures to manage his disease? a) Avoid eating or drinking 2 hours before bedtime. The patient should not ... blocks. d) Eat a low carbohydrate diet The patient is instructed to eat a low-fat diet

Last Answer : a) Avoid eating or drinking 2 hours before bedtime. The patient should not recline with a full stomach.

Which of the following statements about normal salt and water balance are true? A. The products of catabolism may be excreted by as little as 300 ml. of urine per day. B. The lungs represent the primary source of insensible water loss. C. The normal daily insensible water loss is 600 to 900 ml. D. Excessive cell catabolism causes significant loss of total body water. E. In normal humans, urine represents the greatest source of daily water loss.

Description : Which of the following statements about normal salt and water balance are true? A. The products of catabolism may be excreted by as little as 300 ml. of urine per day. B. The lungs represent ... of total body water. E. In normal humans, urine represents the greatest source of daily water loss.

Last Answer : Answer: CE DISCUSSION: The skin is the primary source of insensible water loss. Including losses from the lungs, this averages 600 to 900 ml. per day. Catabolism liberates water of solution. In ... still excrete a minimum of 500 to 800 ml. of urine per day to expel the products of catabolism

When the nurse notes that the patient’s left great toe deviates laterally, she recognizes that the patient has a a) hallux valgus. Hallux valgus is commonly referred to as a bunion. b) hammertoe. Hammertoes are usually pulled upward. c) pes cavus. Pes cavus refers to a foot with an abnormally high arch and a fixed equinus deformity of the forefoot. d) flatfoot. In flatfoot, the patient demonstrates a diminished longitudinal arch of the foot.

Description : When the nurse notes that the patient's left great toe deviates laterally, she recognizes that the patient has a a) hallux valgus. Hallux valgus is commonly referred to as a bunion. b) ... the forefoot. d) flatfoot. In flatfoot, the patient demonstrates a diminished longitudinal arch of the foot.

Last Answer : a) hallux valgus. Hallux valgus is commonly referred to as a bunion.

72. The client is to have surgery in 10 days. Lugol’s solution 4 gtts po was prescribed in 10 days. The client asked the nurse for the purpose of the drug. Which response of the nurse is correct?

Description : 72. The client is to have surgery in 10 days. Lugol’s solution 4 gtts po was prescribed in 10 days. The client asked the nurse for the purpose of the drug. Which response of the nurse is correct?

Last Answer : A. It decreases the risk of bleeding

During a disaster, the nurse sees a victim with a green triage tag. The nurse knows that the person has a) injuries that are minor and treatment can be delayed hours to days. A green triage tag (priority 3 or minimal) indicates injuries that are minor and treatment can be delayed hours to days.

Description : During a disaster, the nurse sees a victim with a green triage tag. The nurse knows that the person has a) injuries that are minor and treatment can be delayed hours to days. A ... or expectant) indicates injuries that are extensive and chances of survival are unlikely even with definitive care.

Last Answer : a) injuries that are minor and treatment can be delayed hours to days. A green triage tag (priority 3 or minimal) indicates injuries that are minor and treatment can be delayed hours to days.

When the patient’s eosinophil count is 50-90% of blood leukocytes, the nurse interprets the result as a) indicative of idiopathic hypereosinophilic syndrome. When eosinophils make up 50-90% of white cell count, the patient is demonstrating severe eosinophilia.

Description : When the patient's eosinophil count is 50-90% of blood leukocytes, the nurse interprets the result as a) indicative of idiopathic hypereosinophilic syndrome. When eosinophils make up 50-90% of white cell ... d) normal. Eosinophils normally make up 1-3% of the total number of white blood cells.

Last Answer : a) indicative of idiopathic hypereosinophilic syndrome. When eosinophils make up 50-90% of white cell count, the patient is demonstrating severe eosinophilia.

Does 4-5 liters of fluid intake per day apply to water?

Description : Do I just have to take in so much water?

Last Answer : No! Includes soup, syrup, anything that contains liquid.

Which nerve is assessed when the nurse asks the patient to dorsiflex the ankle and extend the toes? a) Peroneal The motor function of the peroneal nerve is assessed by asking the patient to dorsiflex the ankle and extend the toes while the sensory function is assessed by pricking the skin between the great and center toes. b) Radial The radial nerve is assessed by asking the patient to stretch out the thumb, then the wrist, and then the fingers at the metacarpal joints. c) Median The median nerve is assessed by asking the patient to touch the thumb to the little finger. d) Ulnar Asking the patient to spread all fingers allows the nurse to assess motor function affected by ulnar innervation.

Description : Which nerve is assessed when the nurse asks the patient to dorsiflex the ankle and extend the toes? a) Peroneal The motor function of the peroneal nerve is assessed by asking the patient to ... the patient to spread all fingers allows the nurse to assess motor function affected by ulnar innervation.

Last Answer : a) Peroneal The motor function of the peroneal nerve is assessed by asking the patient to dorsiflex the ankle and extend the toes while the sensory function is assessed by pricking the skin between the great and center toes.

Which nerve is assessed when the nurse asks the patient to spread all fingers? a) Ulnar Asking the patient to spread all fingers allows the nurse to assess motor function affected by ulnar innervation while pricking the fat pad at the top of the small finger allows assessment of the sensory function affected by the ulnar nerve. b) Peroneal The peroneal nerve is assessed by asking the patient to dorsiflex the ankle and extend the toes. c) Radial The radial nerve is assessed by asking the patient to stretch out the thumb, then the wrist, and then the fingers at the metacarpal joints. d) Median The median nerve is assessed by asking the patient to touch the thumb to the little finger.

Description : Which nerve is assessed when the nurse asks the patient to spread all fingers? a) Ulnar Asking the patient to spread all fingers allows the nurse to assess motor function affected by ulnar innervation ... The median nerve is assessed by asking the patient to touch the thumb to the little finger.

Last Answer : a) Ulnar Asking the patient to spread all fingers allows the nurse to assess motor function affected by ulnar innervation while pricking the fat pad at the top of the small finger allows assessment of the sensory function affected by the ulnar nerve.

The nurse teaches the female patient who is premenopausal to perform breast self-examination (BSE) a) on day 5 to day 7, counting the first day of menses as day 1. BSE is best performed after menses, when less fluid is retained.

Description : The nurse teaches the female patient who is premenopausal to perform breast self-examination (BSE) a) on day 5 to day 7, counting the first day of menses as day 1. BSE is best performed ... retention before their menstrual period, BSE is best performed when the time for menses is taken into account.

Last Answer : a) on day 5 to day 7, counting the first day of menses as day 1. BSE is best performed after menses, when less fluid is retained.

Which of the following statements accurately describes cancer of the esophagus? a) Chronic irritation of the esophagus is a known risk factor. In the United States, cancer of the esophagus has been associated with the ingestion of alcohol and the use of tobacco. b) It is three times more common in women in the U.S. than men. In the United States, carcinoma of the esophagus occurs more than three times as often in men as in women. c) It is seen more frequently in Caucasians than in African Americans. It is seen more frequently in African Americans than in Caucasians. d) It usually occurs in the fourth decade of life. It usually occurs in the fifth decade of life.

Description : Which of the following statements accurately describes cancer of the esophagus? a) Chronic irritation of the esophagus is a known risk factor. In the United States, cancer of the esophagus has been associated ... occurs in the fourth decade of life. It usually occurs in the fifth decade of life.

Last Answer : a) Chronic irritation of the esophagus is a known risk factor. In the United States, cancer of the esophagus has been associated with the ingestion of alcohol and the use of tobacco.

Which of the following patient behaviors, if observed by the nurse, would indicate that the cardiac patient’s level of anxiety has decreased? a) Answers questions regarding status with no problem. Generally, when anxiety begins to increase, the patient will be less likely to want to discuss prognosis.

Description : Which of the following patient behaviors, if observed by the nurse, would indicate that the cardiac patient's level of anxiety has decreased? a) Answers questions regarding status with ... in support groups. Participation in support groups indicates some degree of comfort with prognosis.

Last Answer : a) Answers questions regarding status with no problem. Generally, when anxiety begins to increase, the patient will be less likely to want to discuss prognosis.

Regarding emergency procedures at the burn scene, the nurse teaches which of the following guidelines? a) Never wrap burn victims in ice. Such procedure may worsen the tissue damage and lead to hypothermia in patients with large burns.

Description : Regarding emergency procedures at the burn scene, the nurse teaches which of the following guidelines? a) Never wrap burn victims in ice. Such procedure may worsen the tissue damage and lead to ... . Such procedures may worsen the tissue damage and lead to hypothermia in patients with large burns.

Last Answer : a) Never wrap burn victims in ice. Such procedure may worsen the tissue damage and lead to hypothermia in patients with large burns.

When bowel sounds are heard about every 15 seconds, the nurse would record that the bowel sounds are a) normal. Normal bowel sounds are heard every 5-20 seconds. b) hypoactive. Hypoactive bowel sounds is the description given to auscultation of one to two bowel sounds in 2 minutes. c) sluggish. Sluggish is not a term a nurse would use to accurately describe bowel sounds. d) absent. The nurse records that bowel sounds are absent when no sound is heard in 3-5 minutes.

Description : When bowel sounds are heard about every 15 seconds, the nurse would record that the bowel sounds are a) normal. Normal bowel sounds are heard every 5-20 seconds. b) hypoactive. Hypoactive bowel sounds ... absent. The nurse records that bowel sounds are absent when no sound is heard in 3-5 minutes.

Last Answer : a) normal. Normal bowel sounds are heard every 5-20 seconds.

Halitosis and a sour taste in the mouth are signs and symptoms associated most directly with a) esophageal diverticula. Because the diverticula may retain decomposed food, halitosis and a sour taste in the mouth are frequent complaints. b) achalasia. Achalasia presents as difficulty in swallowing both liquids and solids. c) gastroesophageal reflux. Gastroesophageal reflux presents as burning in the esophagus, indigestion, and difficulty in or pain upon swallowing. d) hiatal hernia. Hiatal hernia presents as heartburn, regurgitation, and dysphagia in many patients while at least 50% are asymptomatic.

Description : Halitosis and a sour taste in the mouth are signs and symptoms associated most directly with a) esophageal diverticula. Because the diverticula may retain decomposed food, halitosis and a sour ... as heartburn, regurgitation, and dysphagia in many patients while at least 50% are asymptomatic.

Last Answer : a) esophageal diverticula. Because the diverticula may retain decomposed food, halitosis and a sour taste in the mouth are frequent complaints.

If tube feeding is continuous, the placement of the feeding tube should be checked a) every shift. Each nurse caring for the patient is responsible for verifying that the tube is located in the proper area for continuous feeding. b) every hour. Checking for placement each hour is unnecessary unless the patient is extremely restless or there is basis for rechecking the tube based on other patient activities. c) every 24 hours. Checking for placement every 24 hours does not meet the standard of care due the patient receiving continuous tube feedings. d) when a tube feeding is continuous, it is unnecessary to check placement. Even though the feedings are continuous, the placement must be assessed.

Description : If tube feeding is continuous, the placement of the feeding tube should be checked a) every shift. Each nurse caring for the patient is responsible for verifying that the tube is located ... is unnecessary to check placement. Even though the feedings are continuous, the placement must be assessed.

Last Answer : a) every shift. Each nurse caring for the patient is responsible for verifying that the tube is located in the proper area for continuous feeding.

57. The client was prescribed Ocreotide acetate (Sandostatin). Nurse Carla would monitor for which of the following side effects?

Description : 57. The client was prescribed Ocreotide acetate (Sandostatin). Nurse Carla would monitor for which of the following side effects?

Last Answer : A. Abdominal pain

54. Albert is prescribed NSAID every four hours to relieve, fever, inflammation, and pericardial pain. To maximize the effect of the drug, the nurse would administer it

Description : 54. Albert is prescribed NSAID every four hours to relieve, fever, inflammation, and pericardial pain. To maximize the effect of the drug, the nurse would administer it

Last Answer : C. Round the clock on a consistent basis

38. A nurse encounters a client who refuses to take a prescribed medication. What is the appropriate action of the nurse?

Description : 38. A nurse encounters a client who refuses to take a prescribed medication. What is the appropriate action of the nurse?

Last Answer : C. Explore the possible reason why the client refuses the prescribed medication

Oncotic pressure refers to a) the osmotic pressure exerted by proteins. Oncotic pressure is a pulling pressure exerted by proteins, such as albumin. b) the number of dissolved particles contained in a unit of fluid. Osmolality refers to the number of dissolved particles contained in a unit of fluid. c) the excretion of substances such as glucose through increased urine output. Osmotic diuresis occurs when the urine output increases due to excretion of substances such as glucose. d) the amount of pressure needed to stop flow of water by osmosis. Osmotic pressure is the amount of pressure needed to stop the flow of water by osmosis.

Description : Oncotic pressure refers to a) the osmotic pressure exerted by proteins. Oncotic pressure is a pulling pressure exerted by proteins, such as albumin. b) the number of dissolved particles contained in a ... . Osmotic pressure is the amount of pressure needed to stop the flow of water by osmosis.

Last Answer : a) the osmotic pressure exerted by proteins. Oncotic pressure is a pulling pressure exerted by proteins, such as albumin.

Which of the following statements most closely reflects the current status of estrogens in postmenopausal women: A. Estrogens should be prescribed routinely to all menopausal women B. Estrogens should be prescribed when menopausal symptoms are severe C. Estrogens should be prescribed only when there is radiological evidence of osteoporosis D. Estrogens should be prescribed along with a progestin after considering risk:benefit ratio in individual patients

Description : Which of the following statements most closely reflects the current status of estrogens in postmenopausal women: A. Estrogens should be prescribed routinely to all menopausal women B. ... should be prescribed along with a progestin after considering risk:benefit ratio in individual patients

Last Answer : . Estrogens should be prescribed along with a progestin after considering risk:benefit ratio in individual patients

The nurse teaches the patient who demonstrates herpes zoster (shingles) that a) the infection results from reactivation of the chickenpox virus. It is assumed that herpes zoster represents a reactivation of latent varicella (chickenpox) virus and reflects lowered immunity.

Description : The nurse teaches the patient who demonstrates herpes zoster (shingles) that a) the infection results from reactivation of the chickenpox virus. It is assumed that herpes zoster represents a ... is arrested if oral antiviral agents are administered within 24 hours of the initial eruption.

Last Answer : a) the infection results from reactivation of the chickenpox virus. It is assumed that herpes zoster represents a reactivation of latent varicella (chickenpox) virus and reflects lowered immunity.