Nokea
Which client requires careful nursing assessment for signs and symptoms of hypomagnesemia?
- A. A young adult client with intractable vomiting from food poisoning
- B. A client who developed hyperparathyroidism in late adolescence
- C. A middle-aged male client in renal failure following an unsuccessful kidney transplant
- D. A female client who is overzealous with her intake of simple carbohydrates
Correct Answer: A
Rationale: The correct answer is A. Vomiting can lead to significant loss of magnesium, causing hypomagnesemia. In this scenario, the young adult client with intractable vomiting from food poisoning is at higher risk of developing hypomagnesemia due to the loss of magnesium through vomiting. Choices B, C, and D are less likely to present with hypomagnesemia. Hyperparathyroidism (B) is associated with hypercalcemia, renal failure (C) can lead to hypermagnesemia, and overconsumption of simple carbohydrates (D) is not directly linked to magnesium imbalances.
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A client is admitted with acute low back pain. What action should the nurse implement to promote comfort?
- A. Ambulate with a walker for upper body support
- B. Perform abdominal curls to stretch the back muscles
- C. Position in semi-Fowler's with the knees flexed
- D. Encourage straight leg raises while lying supine
Correct Answer: C
Rationale: Positioning the client in semi-Fowler's with the knees flexed is the most appropriate action to promote comfort in a client with acute low back pain. This position helps alleviate low back pain by reducing the pressure on the spine and supporting its natural curvature. Ambulating with a walker could strain the back, performing abdominal curls may exacerbate the pain, and straight leg raises while lying supine could cause further discomfort. Therefore, only positioning the client in semi-Fowler's with the knees flexed is the correct choice for promoting comfort in this scenario.
The client demonstrates an understanding of sliding scale insulin administration instructions by performing the procedure in which order?
- A. Obtain blood glucose level
- B. Verify the insulin prescription
- C. Draw insulin into insulin syringe
- D. Cleanse the selected site
Correct Answer: A
Rationale: The correct order for the client to perform the procedure is to first obtain the blood glucose level. This step is crucial as it helps determine the appropriate dose of insulin based on the sliding scale. Verifying the insulin prescription, drawing insulin into the syringe, and cleansing the selected site are important steps in the process but should follow after obtaining the blood glucose level. Therefore, options B, C, and D are incorrect in terms of the initial steps required for sliding scale insulin administration.
Assessment findings of a 3-hour-old newborn include: axillary temperature of 97.7°F, heart rate of 140 beats/minute with a soft murmur, and irregular respiratory rate at 42 breaths/min. Based on these findings, what action should the nurse implement?
- A. Place a pulse oximeter on the heel
- B. Swaddle the infant in a warm blanket
- C. Record the findings on the flow sheet
- D. Check the vital signs in 15 minutes
Correct Answer: C
Rationale: The correct action for the nurse to take in this scenario is to record the findings on the flow sheet. The newborn's axillary temperature, heart rate, and respiratory rate are within normal limits for a 3-hour-old newborn. Therefore, there is no immediate need for intervention or further assessment. Swaddling the infant in a warm blanket, placing a pulse oximeter on the heel, or checking the vital signs in 15 minutes are not necessary actions based on the normal assessment findings presented. These actions could potentially disrupt the newborn or lead to unnecessary interventions when the baby is stable.
The parents of a 6-year-old recently diagnosed with asthma should be taught that the symptom of acute episodes of asthma is due to which physiological response?
- A. Inflammation of the mucous membrane & bronchospasm
- B. Increased mucus production and bronchoconstriction
- C. Allergic reactions and hyperventilation
- D. Airway narrowing and decreased lung capacity
Correct Answer: A
Rationale: The correct answer is A: Inflammation of the mucous membrane & bronchospasm. Acute asthma episodes are primarily caused by inflammation of the airways and bronchospasm, which lead to airway obstruction. Increased mucus production and bronchoconstriction (Choice B) are part of the physiological responses in asthma but do not directly cause acute episodes. Allergic reactions and hyperventilation (Choice C) are related to asthma triggers and responses but are not the direct causes of acute episodes. Airway narrowing and decreased lung capacity (Choice D) are consequences of inflammation and bronchospasm but do not explain the physiological response leading to acute asthma episodes.
A group of nurses implemented a pilot study to evaluate a proposed evidence-based change to providing client care. Evaluation indicates successful outcomes, and the nurses want to integrate the change throughout the facility. Which action should be taken? (Select all that apply)
- A. Invite data review by the quality improvement department
- B. Submit a sentinel event report to the research committee
- C. Propose clinical practice guidelines to the nursing committee
- D. Arrange in-service training through the educational department
Correct Answer: A
Rationale: Inviting data review by the quality improvement department is crucial to ensure the quality and efficacy of the proposed evidence-based change. This step allows for a comprehensive analysis of the data collected during the pilot study. Proposing clinical practice guidelines to the nursing committee is also essential for integrating the successful change into routine practice. In-service training through the educational department will help educate staff and ensure they are proficient in implementing the new practices. Submitting a sentinel event report to the research committee is not necessary in this scenario as the outcomes were successful, and there were no adverse events that would warrant such a report. Choices B, C, and D are not as relevant in this context compared to inviting data review by the quality improvement department, which is a crucial step in ensuring the success of the proposed change.