Nokea
A nurse reviews the electrolyte results of an assigned client and notes that the potassium level is 5.4 mEq/L. Which of the following would the nurse expect to note on the electrocardiogram as a result of the laboratory value?
- A. ST depression
- B. Inverted T wave
- C. Prominent U wave
- D. Tall peaked T waves
Correct Answer: D
Rationale: The correct answer is 'Tall peaked T waves.' Tall peaked T waves are characteristic ECG changes associated with hyperkalemia. In hyperkalemia, the elevated potassium levels affect the myocardium, leading to changes in the ECG. ST depression (Choice A) is more commonly associated with myocardial ischemia or infarction. Inverted T wave (Choice B) is seen in conditions like myocardial ischemia or CNS events. Prominent U wave (Choice C) is typically associated with hypokalemia or certain medications. Therefore, in this scenario, the nurse would expect to note tall peaked T waves on the electrocardiogram due to the elevated potassium level.
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How many calories per kilogram does an average full-term infant require when the infant is around 1-2 months old?
- A. 140 calories per kilogram per day
- B. 120 calories per kilogram per day
- C. 100 calories per kilogram per day
- D. 160 calories per kilogram per day
Correct Answer: B
Rationale: An average full-term infant requires about 120 calories per kilogram per day at 1-2 months old. This amount is essential for their growth and development during this critical stage. Choices A, C, and D are incorrect as they provide calorie amounts that are either too high or too low for an average full-term infant at 1-2 months old, which could potentially lead to health issues or inadequate nutrition.
A nurse reviews a client's laboratory report and notes that the client's serum phosphorus level is 2.0 mg/dL. Which condition most likely caused this serum phosphorus level?
- A. Alcoholism
- B. Renal insufficiency
- C. Hypoparathyroidism
- D. Tumor lysis syndrome
Correct Answer: A
Rationale: The correct answer is A: Alcoholism. Alcoholism can lead to hypophosphatemia due to poor dietary intake and other factors. Excessive alcohol consumption can result in malnutrition, particularly a deficiency in phosphorus. Choices B, C, and D are unlikely to cause low serum phosphorus levels. Renal insufficiency is more likely to cause hyperphosphatemia, hypoparathyroidism is associated with hypocalcemia rather than hypophosphatemia, and tumor lysis syndrome typically presents with hyperphosphatemia due to the release of intracellular phosphate.
While administering penicillin intravenously, you notice that the patient becomes hypotensive with a bounding, rapid pulse rate. What is the first action you should take?
- A. Decrease the rate of the intravenous medication flow.
- B. Increase the rate of the intravenous medication flow.
- C. Call the doctor.
- D. Stop the intravenous flow.
Correct Answer: D
Rationale: The correct action to take when a patient becomes hypotensive with a bounding, rapid pulse rate after administering penicillin intravenously is to stop the intravenous flow immediately. This can help prevent further complications by discontinuing the administration of the medication that might be causing the adverse effects. Decreasing or increasing the rate of medication flow may not address the underlying issue of the patient's adverse reaction. While it's important to involve the healthcare provider in such situations, the immediate priority is to halt the administration of the medication.
A client with a tumor refuses surgery, but the client's partner wants it. Which is the deciding factor in determining if the surgery will be done?
- A. Whether the partner is the client's durable power of attorney for healthcare
- B. Whether the client understands the risk of refusing the procedure
- C. Whether the client's refusal is based on religious belief
- D. Whether the facility's ethical committee reaches a consensus on the case
Correct Answer: B
Rationale: The correct answer is B because the client's understanding of the risks involved in refusing the surgery is crucial in determining the course of action. In this scenario, the client's autonomy and decision-making capacity take precedence. Choice A is not directly relevant to the decision-making process regarding surgery. Choice C, religious beliefs, may influence the decision but should not be the determining factor in this case. Choice D involving the facility's ethical committee is not typically involved in individual patient care decisions.
A nurse is receiving a verbal prescription from the provider for a client who is experiencing increased pain. The nurse should transcribe which of the following prescriptions in the client's medical record?
- A. Morphine sulfate 10 mg IV q 4 IV prn for pain
- B. MS 10 mg IV every 4 8 prn for pain
- C. MSO4 10 mg IVP q 4 8 prn for pain
- D. Morphine sulfate 10.0 mg every 4 hours IV prn for pain
Correct Answer: A
Rationale: The correct transcription is 'Morphine sulfate 10 mg IV q 4 IV prn for pain.' In choice A, 'Morphine sulfate 10 mg IV q 4 IV prn for pain' correctly indicates the medication, route (IV), frequency (every 4 hours), and administration as needed for pain control. Choice B is incorrect as 'MS' is not a standard abbreviation for Morphine Sulfate, and the frequency 'every 4 8' is not a valid time interval. Choice C is incorrect as 'MSO4' is not the standard abbreviation for Morphine Sulfate, and 'IVP' is not the standard route abbreviation for intravenous. Choice D is incorrect as it lacks clarity with '10.0 mg' instead of '10 mg,' and the frequency is given as 'every 4 hours' without specifying the route of administration.