Nokea
The healthcare provider is caring for a client with hypokalemia. Which assessment finding requires immediate intervention?
- A. Muscle weakness.
- B. Irregular heart rate.
- C. Increased urinary output.
- D. Decreased deep tendon reflexes.
Correct Answer: D
Rationale: Decreased deep tendon reflexes are a critical finding in hypokalemia that indicates severe potassium deficiency affecting neuromuscular function. Immediate intervention is necessary to prevent life-threatening complications such as respiratory failure or cardiac arrhythmias. Muscle weakness, irregular heart rate, and increased urinary output are also associated with hypokalemia but do not pose the same level of urgency as decreased deep tendon reflexes.
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A client with a history of peptic ulcer disease is admitted with sudden severe abdominal pain. Which finding indicates the possibility of a perforated ulcer?
- A. Bowel sounds are hyperactive in all quadrants.
- B. Abdomen is soft and nondistended.
- C. The client reports sudden severe abdominal pain.
- D. Blood pressure of 110/70 mm Hg.
Correct Answer: C
Rationale: The correct answer is C. Sudden severe abdominal pain is a key clinical manifestation of a perforated ulcer. The sudden onset of severe pain is concerning for a perforation in the ulcer, which can lead to peritonitis if not promptly addressed. Choices A, B, and D are incorrect because hyperactive bowel sounds, a soft and nondistended abdomen, and a blood pressure of 110/70 mm Hg are not specific indicators of a perforated ulcer. Hyperactive bowel sounds may suggest increased gastrointestinal motility, a soft abdomen may not necessarily indicate a perforation, and a blood pressure of 110/70 mm Hg is within normal limits and does not directly relate to a perforated ulcer.
The healthcare provider is assessing a client with a suspected pulmonary embolism. Which finding requires immediate intervention?
- A. Chest pain.
- B. Shortness of breath.
- C. Tachycardia.
- D. Cyanosis.
Correct Answer: D
Rationale: Cyanosis is a late sign of hypoxemia and indicates severe oxygen deprivation, necessitating immediate intervention in a client with a suspected pulmonary embolism. Chest pain, shortness of breath, and tachycardia are also concerning symptoms in pulmonary embolism; however, cyanosis signifies critical oxygen deficiency and warrants urgent attention to prevent further complications.
The nurse is providing care for a client with syndrome of inappropriate antidiuretic hormone (SIADH). Which laboratory result requires immediate intervention?
- A. Serum sodium of 140 mEq/L.
- B. Serum potassium of 4.5 mEq/L.
- C. Serum osmolality of 280 mOsm/kg.
- D. Serum sodium of 130 mEq/L.
Correct Answer: D
Rationale: The correct answer is D: Serum sodium of 130 mEq/L. In SIADH, there is excess release of antidiuretic hormone leading to water retention and dilutional hyponatremia. A serum sodium level of 130 mEq/L indicates severe hyponatremia, which can result in neurological symptoms, such as confusion, seizures, and coma. Therefore, immediate intervention is required to prevent further complications. Choice A, a serum sodium of 140 mEq/L, is within the normal range and does not require immediate intervention. Choice B, serum potassium of 4.5 mEq/L, is also within the normal range and is not directly related to SIADH. Choice C, serum osmolality of 280 mOsm/kg, is a measure of the concentration of solutes in the blood and may not be the most critical parameter to address in a client with SIADH and severe hyponatremia.
The instructor is teaching a prenatal class about the importance of folic acid. Which outcome indicates that the teaching was effective?
- A. participants can list foods high in folic acid
- B. participants plan to take folic acid supplements daily
- C. participants understand the risks of folic acid deficiency
- D. participants demonstrate how to read nutrition labels for folic acid content
Correct Answer: B
Rationale: The correct answer is B because planning to take folic acid supplements daily is a proactive step towards preventing folic acid deficiency and reducing the risk of neural tube defects in pregnancy. While choice A is important for dietary knowledge, the direct action of taking supplements is more effective. Choice C, understanding the risks, is good but does not ensure action. Choice D, reading nutrition labels, is helpful but doesn't guarantee intake of folic acid.
When visiting a community health clinic, a client's blood pressure is measured at 146/94. What information should the nurse provide the client?
- A. Participate in an exercise program for 6 weeks
- B. Obtain blood pressure daily for 2 weeks
- C. Increase dietary intake of omega-3 fatty acids
- D. Begin a low sodium diet immediately
Correct Answer: D
Rationale: The correct answer is to advise the client to begin a low sodium diet immediately. High sodium intake can contribute to elevated blood pressure levels. By reducing sodium intake, blood pressure can be effectively lowered. Option A, participating in an exercise program, is beneficial for overall health but may not provide immediate impact on blood pressure. Option B, obtaining blood pressure daily for 2 weeks, may not address the underlying cause or provide immediate intervention. Option C, increasing dietary intake of omega-3 fatty acids, though beneficial for heart health, may not have an immediate impact on lowering blood pressure compared to reducing sodium intake.