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Questions 164

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Question 1 of 5

A client diagnosed with acute glomerulonephritis has pitting edema in the lower extremities, a blood pressure of 170/80 mm Hg, and proteinuria. When the practical nurse is assisting in the development of a care plan for this client, which measurement is the most accurate indicator of fluid loss or gain and should therefore be included in the plan?

Correct Answer: B

Rationale: Daily weights (
B) are the most accurate for tracking fluid balance in glomerulonephritis. Blood pressure (
A), edema (
C), and intake/output (
D) are less precise.

Question 2 of 5

A 31-year-old client is admitted to the psychiatric unit after cutting both wrists with a kitchen knife. The client has a diagnosis of borderline personality disorder. The most therapeutic approach by the nurse is one that is:

Correct Answer: C

Rationale: A firm and consistent approach provides structure and boundaries, which are therapeutic for clients with borderline personality disorder who often test limits.

Question 3 of 5

The nurse is teaching a client with cardiac disease about the anatomy and physiology of the heart. Which is the correct pathway of blood flow through the heart?

Correct Answer: C

Rationale: Right atrium, right ventricle, left atrium, left ventricle. This is the correct pathway of blood flow through the heart.

Question 4 of 5

A woman is pregnant for the first time and is Rh negative. Her husband is Rh positive. She tells the nurse that he is very worried about her baby. Which information should the nurse plan to include when talking with this woman?

Correct Answer: A

Rationale: The first Rh-positive baby is typically unaffected as maternal antibodies develop post-delivery. RhoGAM is given after birth to prevent issues in future pregnancies, not after the second baby.

Question 5 of 5

Following cardiac surgery, a client's urine output for the last hour is 20 mL. The nurse understands that this indicates which of the following?

Correct Answer: B

Rationale: Low urine output (20 mL/hour) post-cardiac surgery suggests insufficient cardiac output, impairing renal perfusion. Hyperkalemia, inadequate fluids, or diuresis are less likely causes without additional signs.

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