Nokea
The nurse is assigned to care for 4 clients. Which of the following should be assessed immediately after hearing the report?
- A. The client with asthma who is now ready for discharge
- B. The client with a peptic ulcer who has been vomiting all night
- C. The client with chronic renal failure returning from dialysis
- D. The client with pancreatitis who was admitted yesterday
Correct Answer: B
Rationale: The client with a peptic ulcer who has been vomiting all night. Persistent vomiting can lead to dehydration, electrolyte imbalances, and potential complications such as perforation or bleeding in a client with a peptic ulcer, requiring immediate assessment.
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The nurse is reviewing prescriptions for assigned adult clients. The nurse should question the prescription for
- A. 0.45% sodium chloride for a client with syndrome of inappropriate antidiuretic hormone secretion who has a decreased sodium level
- B. 0.9% sodium chloride for a client with gastrointestinal bleeding who has a decreased hemoglobin level
- C. 1,000 mL bolus of 0.9% sodium chloride for a client with septic shock who has an increased WBC count
- D. lactated Ringer solution for a client with hypovolemic shock and a thermal burn who has an increased hematocrit level
Correct Answer: A
Rationale: 0.45% sodium chloride is hypotonic and can worsen hyponatremia in SIADH by further diluting serum sodium, requiring clarification for a hypertonic solution.
A client is receiving nitroprusside IV for the treatment of acute heart failure with pulmonary edema. What diagnostic lab value should the nurse monitor when a client is receiving this medication?
- A. Potassium level
- B. Arterial blood gasses
- C. Blood urea nitrogen
- D. Thiocyanate
Correct Answer: D
Rationale: Thiocyanate. Nitroprusside metabolism increases thiocyanate levels, which can lead to cyanide toxicity if elevated.
The nurse is talking with a client who has urge incontinence and is receiving tolterodine. It would require immediate follow-up if the client reports
- A. straining to have a bowel movement
- B. going an entire workday without needing to urinate
- C. using over-the-counter artificial saliva products for dry mouth
- D. experiencing occasional dizziness in the morning and with position changes
Correct Answer: B
Rationale: Not urinating for an entire workday suggests urinary retention, a serious side effect of tolterodine, requiring immediate evaluation to prevent bladder damage.
The client is admitted with hypokalemia. An IV of normal saline is infusing at $80 \mathrm{ml} /$ hour with 10 meq of $\mathrm{KCl} /$ hour. Prior to beginning the infusion, the nurse should:
- A. Check the sodium level.
- B. Check the magnesium level.
- C. Check the creatinine level.
- D. Check the calcium level.
Correct Answer: B
Rationale: Hypokalemia is often associated with hypomagnesemia, which can impair potassium correction. Checking the magnesium level ensures effective treatment. Sodium , creatinine , and calcium levels are less directly related to potassium infusion safety.
The nurse is assisting with the care of a client who has diabetic ketoacidosis. The nurse should recognize that it is a priority to
- A. gather supplies for an IV bolus of 0.9% sodium chloride
- B. prepare the client for an IV infusion of regular insulin
- C. request a prescription for potassium chloride
- D. obtain a urine specimen for urinalysis
Correct Answer: B
Rationale: In diabetic ketoacidosis, insulin administration is the priority to correct hyperglycemia and halt ketogenesis, addressing the underlying metabolic crisis.