Exhibits

Review the exhibits and click to mark whether each assessment finding represents a therapeutic result of the furosemide administered, a non-therapeutic side effect, or an unrelated finding. Each row must have one option selected.

Potassium 3.1 mEq/L

Prothrombin time/International normalized ratio (INR) 2.2

Urine output: 600 mL

Potassium 3.1 mEq/L

Prothrombin time/INR 2.2

Urine output: 600 mL

Answer and Explanation

The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"C"},"C":{"answers":"A"}}

Based on the question and the known effects of furosemide, here’s how each assessment finding can be categorized:

Potassium 3.1 mEq/L: This is a non-therapeutic side effect. Furosemide is a diuretic that increases the excretion of water, sodium, and potassium from the body. This can lead to hypokalemia, or low potassium levels.
Prothrombin time/INR 2.2: This is likely an unrelated finding. Furosemide does not typically affect prothrombin time or INR. However, the patient is also taking warfarin, which is an anticoagulant known to increase INR.
Urine output: 600 mL: This is a therapeutic result. Furosemide works by increasing the amount of urine the body makes, which helps reduce swelling and symptoms of fluid retention.

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Correct Answer is B

Explanation

Choice A rationale

Determining the amount of weight the patient has lost since increasing activity is relevant to the patient’s overall health and progress toward weight loss goals, but it does not directly address the issue of sleep difficulties. Weight loss and improved sleep may not always have a direct cause-and-effect relationship.

Choice B rationale

Inquiring about the patient’s exercise schedule is a reasonable action. It allows the nurse to gather information about the patient’s exercise routine and assess whether it might be contributing to the sleep difficulties. For instance, exercising too close to bedtime can interfere with sleep. Therefore, understanding the timing and intensity of the patient’s exercise can provide valuable insights into potential adjustments that could improve sleep quality.

Choice C rationale

Informing the patient that lifestyle changes often take several weeks to be effective is a general statement that might not address the specific concerns of the patient. While it’s true that lifestyle changes, including exercise, can take time to show results, this does not provide a targeted solution to the patient’s reported difficulty in falling asleep.

Choice D rationale

Encouraging the patient to exercise daily to reduce bedtime wakefulness is not appropriate advice in this scenario. It oversimplifies the issue and may not address the underlying causes of the patient’s sleep difficulties. Additionally, excessive exercise close to bedtime may actually interfere with sleep.

A. Auscultate an area six inches below the umbilicus. B. Observe the appearance of the patient’s urine. C. Palpate the area above the pubic symphysis. D. Measure the girth of the patient’s lower abdomen.

Correct Answer is C

Explanation

Choice A rationale

Auscultating an area six inches below the umbilicus would not provide the most useful data when assessing for possible urinary retention. Auscultation is typically used to assess bowel sounds and not typically used in the assessment of urinary retention.

Choice B rationale

Observing the appearance of the patient’s urine can provide some information about the patient’s hydration status and kidney function, but it would not be the most useful technique for assessing urinary retention.

Choice C rationale

Palpating the area above the pubic symphysis can provide useful data when assessing for possible urinary retention. If the bladder is distended due to urinary retention, it may be palpable in this area.

Choice D rationale

Measuring the girth of the patient’s lower abdomen is not typically used as a method to assess for urinary retention. While an increase in abdominal girth can occur with urinary retention, it is not the most direct or reliable method for assessment.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient informs the nurse about starting an exercise program a month ago to lose weight and improve sleep.The patient states, “It still takes at least two hours to fall asleep at night.”. What action should the nurse take?

Correct Answer is B

Explanation

Which assessment technique would provide the most useful data when the nurse is concerned about possible urinary retention?

Correct Answer is C

Explanation

A nurse is providing dietary advice to a patient with hypertension.Which food item would be the best choice for the patient’s lunch?

A young adult is admitted to the emergency department after consuming an unknown quantity of drugs.The patient is unresponsive, and an endotracheal tube (ETT) has been inserted.What methods should the nurse use to confirm the correct placement of the ETT? Select all that apply.

A healthcare provider prescribes a low-fiber diet for a patient with ulcerative colitis.Which food selection by the patient indicates to the nurse that the patient understands the prescribed diet?

The patient is resting in bed and cooperative with her mother at her bedside. Which of the following assessments were made?

A client admitted with pneumonia and on bedrest has not had the strength to perform self-care.Which assessment finding provides the nurse with the earliest indication that the client is developing a pressure injury?

The healthcare provider prescribes the antibiotic cefdinir 300 mg PO every 12 hours for a client with a postoperative wound infection.What foods should the nurse encourage this client to eat?

A nurse is assessing a 3-month-old patient who underwent a pyloromyotomy the previous day.Which of the following findings would indicate a need for pain medication? Select all that apply.