Nokea
Complete the following sentence by using the lists of options. The nurse understands that the patient has likely developed-----and will need to be monitored for-------
- A. Lithium toxicity
- B. Hyponatremia
- C. cardiac dysrhythmias
- D. nephrotoxicity
- E. metabolic alkalosis
- F. Hypertension
Correct Answer: A,D
Rationale: The correct answer is A and D. Lithium toxicity and nephrotoxicity are commonly associated with the use of lithium. The nurse needs to monitor the patient for signs and symptoms of lithium toxicity, such as tremors, confusion, and increased thirst, as well as signs of nephrotoxicity, like decreased urine output and electrolyte imbalances. Hyponatremia (B), cardiac dysrhythmias (C), metabolic alkalosis (E), and hypertension (F) are not directly related to lithium use. Monitoring for these conditions would not be the priority in a patient who has likely developed lithium toxicity and nephrotoxicity.
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A nurse and an assistive personnel (AP) are assigned a group of clients on the unit. Which of the following clients should the nurse instruct the AP to report to the nurse?
- A. A client who requests assistance to use the bedside commode
- B. A client who has a prescription for compression stockings and did not receive them
- C. A client who requests to sit in the bedside chair while watching TV
- D. A client who consumes all the food from their meal tray
Correct Answer: B
Rationale: Correct Answer: B - A client who has a prescription for compression stockings and did not receive them should be reported to the nurse.
Rationale: Compression stockings are a prescribed medical intervention for a specific reason, such as preventing blood clots or managing edema. Failure to provide them can lead to serious health consequences. The nurse needs to be informed immediately to address this issue promptly.
Summary of Other Choices:
A: A client requesting assistance to use the bedside commode is within the scope of the AP's duties and does not require immediate nurse intervention.
C: A client requesting to sit in a bedside chair is a basic comfort measure and does not require immediate nurse intervention.
D: A client consuming all the food from their meal tray is not a cause for immediate concern and does not require nurse intervention at that moment.
A nurse is collecting a sputum specimen from a client who has tuberculosis. Which of the following actions should the nurse take?
- A. Wait 1 day to collect the specimen if the client cannot provide sputum.
- B. Wear sterile gloves to collect the specimen from the client.
- C. Ask the client to provide 15 to 20 mL of sputum into the container
- D. Obtain the specimen immediately upon the client waking up.
Correct Answer: D
Rationale: The correct answer is D: Obtain the specimen immediately upon the client waking up. This is the correct action because sputum is most concentrated in the morning, making it easier to collect a good sample for testing. Waiting 1 day (A) can delay treatment. Wearing sterile gloves (B) is important but not specific to sputum collection. Asking for 15-20mL of sputum (C) is appropriate, but the timing of collection is crucial.
A nurse in an emergency department is caring for a 3-year-old child who has suspected epiglottitis. Which of the following actions should the nurse take?
- A. Prepare to assist with intubation.
- B. Obtain a throat culture.
- C. Suction the child's oropharynx.
- D. Prepare a cool mist tent
Correct Answer: A
Rationale: The correct answer is A: Prepare to assist with intubation. Epiglottitis is a medical emergency where the swelling of the epiglottis can rapidly obstruct the airway, leading to respiratory distress or failure. Intubation is crucial to secure the airway and ensure adequate oxygenation. Obtaining a throat culture (B) may delay necessary intervention. Suctioning the oropharynx (C) can trigger spasm and worsen the obstruction. Cool mist tent (D) does not address the immediate need for securing the airway.
Drag words from the choices below to fill in each blank in the following sentence. The client is at greatest risk for developing-----and-----
- A. Placental Abruption
- B. Hypoglycemia
- C. Heart failure
- D. Cervical insufficiency
- E. Seizures
Correct Answer: C,E
Rationale: The correct answer is C, Heart failure, and E, Seizures. The client is at greatest risk for developing heart failure and seizures due to complications during pregnancy. Heart failure can occur due to the increased stress on the heart from pregnancy, especially in individuals with pre-existing heart conditions. Seizures can arise from conditions like eclampsia, which is a severe form of preeclampsia characterized by high blood pressure and organ damage. Placental abruption (A) is a separation of the placenta from the uterus, not directly related to heart failure or seizures. Hypoglycemia (B) is low blood sugar levels, which may occur but is not the greatest risk in this scenario. Cervical insufficiency (D) is the inability of the cervix to stay closed during pregnancy, which is not directly linked to heart failure or seizures.
For each potential assessment finding, click to specify if the assessment finding is consistent with mastitis or endometritis. Each finding may support more than 1 disease process.
- A. Foul-smelling lochia
- B. Painful, tender breast
- C. Temperature
- D. Chills
Correct Answer: B: Mastitis; A, C, D: Both
Rationale: The correct answer is B: Painful, tender breast - consistent with mastitis. Mastitis is an infection of the breast tissue, causing pain and tenderness. A: Foul-smelling lochia can be seen in both mastitis and endometritis. C: Temperature can be elevated in both conditions due to infection. D: Chills can also be present in both mastitis and endometritis as a response to infection. The other choices are left blank as they do not specifically align with either mastitis or endometritis in terms of assessment findings.