Nokea
Clients taking lithium must be particularly sure to maintain adequate intake of which of these elements?
- A. Potassium
- B. Sodium
- C. Chloride
- D. Calcium
Correct Answer: B
Rationale: Clients taking lithium need to maintain an adequate intake of sodium. Serum lithium concentrations may increase in the presence of conditions that cause sodium loss.
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The nurse is caring for a client who has a prescription for insulin lispro 1 unit subcutaneously per 15 g of carbohydrates with each meal. The client's meal contains 75 g of carbohydrates. How many units of insulin lispro should the nurse administer to the client? Record your answer using a whole number.
Correct Answer: 5
Rationale: 75 g carbohydrates ÷ 15 g/unit = 5 units of insulin lispro.
Written instructions to pregnant women include instructions to perform Kegel exercises. One of the women asks the nurse why these exercises are important. The nurse should reply that the purpose of these exercises is to:
- A. increase circulation to the uterus.
- B. strengthen the muscles of the pelvic floor.
- C. prepare the breasts for nursing.
- D. condition the pregnant woman for the 'work' of childbirth.
Correct Answer: B
Rationale: Kegel exercises strengthen pelvic floor muscles, supporting bladder control and aiding postpartum recovery, directly addressing their purpose.
The nurse is caring for a client with trigeminal neuralgia (tic douloureux). To assist the client with nutrition needs, the nurse should
- A. Offer small meals of high calorie soft food
- B. Assist the client to sit in a chair for meals
- C. Provide additional servings of fruits and raw vegetables
- D. Encourage the client to eat fish, liver and chicken
Correct Answer: A
Rationale: Offer small meals of high calorie soft food. High-calorie soft foods minimize chewing, providing nourishment with less pain.
The nurse is caring for a client with partial hearing loss. Which of the following actions will promote effective communication? Select all that apply.
- A. Dim lights to prevent overstimulation
- B. Directly face the client when speaking
- C. Ensure hearing aids are properly applied
- D. Provide written information to supplement conversation
- E. Raise voice to speak loudly to the client
Correct Answer: B,C,D
Rationale: Facing the client aids lip-reading, properly applied hearing aids optimize hearing, and written information reinforces verbal communication. Dimming lights may hinder lip-reading, and shouting distorts speech.
After assisting a client with a lower gastrointestinal bleed back to bed, the nurse finds approximately 600 mL of frank red blood in the toilet. The client is pale and diaphoretic and reports dizziness. Which action should the nurse perform first?
- A. Document the output and vital signs
- B. Draw blood for hemoglobin and hematocrit
- C. Lower the head of the bed
- D. Notify the registered nurse
Correct Answer: C
Rationale: Significant bleeding (600 mL), pallor, diaphoresis, and dizziness suggest hypovolemia. Lowering the head of the bed improves cerebral perfusion, stabilizing the client. Notification, labs, and documentation follow stabilization.