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1. A nurse is caring for an infant who is receiving IV fluids for dehydration. Which of the following should the nurse recognize as a positive response to the therapy?
- A. Tachycardia
- B. Hypotension
- C. Increased urine output
- D. Diarrhea
Correct answer: C
Rationale: Increased urine output is a positive sign that the IV fluids are effectively treating dehydration. Tachycardia (choice A) and hypotension (choice B) are signs of dehydration and would not be considered positive responses to therapy. Diarrhea (choice D) can worsen dehydration and is not a positive response to IV fluid therapy.
2. What intervention is essential for a client with dehydration?
- A. Monitor electrolyte levels regularly
- B. Administer oral rehydration solutions
- C. Increase fluid intake to maintain hydration
- D. Administer intravenous fluids to treat dehydration
Correct answer: B
Rationale: Administering oral rehydration solutions is essential for a client with dehydration as it helps replenish lost fluids and electrolytes directly through the oral route. Monitoring electrolyte levels regularly (Choice A) is important but not as essential as providing immediate rehydration. Increasing fluid intake to maintain hydration (Choice C) may not be sufficient for a client already dehydrated and needing rapid replenishment. Administering intravenous fluids (Choice D) is a more invasive intervention typically reserved for severe cases of dehydration or when the client cannot tolerate oral fluids.
3. A client with a new prescription for prednisone for the treatment of Addison's disease needs teaching. Which instruction should the nurse include?
- A. Take the medication with food
- B. Avoid taking aspirin
- C. Schedule a bone density test
- D. Expect increased appetite
Correct answer: C
Rationale: The correct instruction for the nurse to include is to schedule a bone density test. Prednisone can lead to reduced bone density, making regular monitoring crucial for clients on long-term therapy. Instructing the client to take the medication with food (choice A) or avoid taking aspirin (choice B) are not directly related to prednisone therapy for Addison's disease. While prednisone can cause increased appetite, it is not the priority instruction in this scenario, compared to monitoring bone density (choice D).
4. A client who has undergone vein ligation and stripping to treat varicose veins should be instructed to do which of the following activities during discharge teaching?
- A. Remain sedentary for 2-3 days
- B. Walk for 1-2 hours each day
- C. Wear compression stockings only at night
- D. Elevate legs while sitting
Correct answer: B
Rationale: The correct answer is B: 'Walk for 1-2 hours each day.' After vein ligation and stripping, walking helps promote circulation and aids in the recovery process. Option A is incorrect as remaining sedentary for 2-3 days can lead to decreased circulation and potentially increase the risk of complications. Option C is incorrect because compression stockings should typically be worn during the day to support circulation. Option D is incorrect as elevating the legs while sitting is beneficial, but walking is more effective in promoting circulation and recovery in this case.
5. A nurse is caring for a client who has pneumonia and new onset confusion. Which of the following actions should the nurse take first?
- A. Increase the client's oxygen flow rate
- B. Obtain the client's vital signs
- C. Administer an antibiotic
- D. Notify the provider
Correct answer: A
Rationale: Correct Answer: Increasing the client's oxygen flow rate should be the nurse's first action. Hypoxia is a common complication of pneumonia and can lead to confusion. Providing adequate oxygenation is essential in addressing hypoxia and improving the client's condition.\nOption B: Obtaining vital signs is important but addressing hypoxia takes precedence in the setting of new onset confusion.\nOption C: Administering an antibiotic is important for treating pneumonia but addressing hypoxia and confusion is the priority.\nOption D: Notifying the provider may be necessary but addressing the immediate physiological need of oxygenation should come first.
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