Nokea
An adult who has gastroenteritis and is on digitalis ha lab values of: K 3.2 mEq/L, Na 136 mEq/L, Ca 8.8 mg/dl, and Cl 98 mEq/L. the nurse puts which of the following on the client’s plan of care?
- A. Stop digitalis therapy
- B. Observe for trousseau’s and chovestek’s
- C. Avoid foods rich in potassium signs
- D. Observe for digitalis toxicity
Correct Answer: C
Rationale: Step-by-step rationale for why choice C is correct:
1. The lab value of K at 3.2 mEq/L indicates hypokalemia.
2. Digitalis can worsen hypokalemia and lead to toxicity.
3. Avoiding foods rich in potassium will prevent further lowering of potassium levels.
4. This intervention helps prevent potential digitalis toxicity in the client.
Summary of why the other choices are incorrect:
A. Stopping digitalis therapy abruptly can lead to rebound effects and worsen the condition.
B. Trousseau's and Chvostek's signs are not relevant to the client's current lab values.
D. While observing for digitalis toxicity is important, addressing the low potassium level is a more immediate concern in this scenario.
You may also like to solve these questions
The client with myasthenia gravis has become increasingly weaker. The physician prepares to identify whether the client is reacting to an overdose of the medication (cholinergic crisis) or an increasing severity of the disease (myasthenic crisis). An injection of edrophonium (Tensilon) is administered. Which of the following would indicate that the client is in cholinergic crisis?
- A. No change in the condition
- B. An improvement of the weakness
- C. Complaints of muscle spasms
- D. A temporary worsening of the condition
Correct Answer: B
Rationale: The correct answer is B: An improvement of the weakness. Edrophonium is a short-acting cholinesterase inhibitor that helps differentiate between myasthenic and cholinergic crises in myasthenia gravis. In cholinergic crisis, there is an overdose of cholinesterase inhibitors leading to excessive acetylcholine at the neuromuscular junction, causing muscle weakness. Administering edrophonium will temporarily improve muscle weakness in cholinergic crisis due to the increased availability of acetylcholine. The other choices are incorrect because: A: No change suggests the client is not in cholinergic crisis. C: Complaints of muscle spasms are more indicative of myasthenic crisis. D: A temporary worsening of the condition is not expected in cholinergic crisis.
Which of the following is an example of a well-stated nursing intervention?
- A. Client will drink 100 mL of water every 2 hours while awake.
- B. Offer client 100 mL of water every 2 hours while awake.
- C. Offer client water when he complains of thirst.
- D. Client will continue to increase oral intake when awake.
Correct Answer: B
Rationale: The correct answer is B because it provides a specific action (offering water) at regular intervals (every 2 hours) to promote hydration, which is a clear and measurable nursing intervention. Choice A is too prescriptive and lacks flexibility. Choice C is reactive and not proactive. Choice D is vague and lacks specific guidance on how to achieve the desired outcome. By offering water consistently, the nurse ensures proactive care and helps meet the client's hydration needs effectively.
The nurse is caring for a client with bronchogenic carcinoma. Which nursing diagnosis takes highest priority?
- A. Disturbed body image related to changes in body functions
- B. Ineffective airway clearance related to obstruction by a tumor or secretions
- C. Anxiety related to actual threat to health status and changes in family dynamics
- D. Imbalanced nutrition: Less than body requirements related to anorexia and vomiting secondary to chemotherapy
Correct Answer: B
Rationale: The correct answer is B: Ineffective airway clearance related to obstruction by a tumor or secretions. This is the highest priority because compromised airway clearance can lead to life-threatening complications such as respiratory distress or hypoxia. Ensuring effective airway clearance is crucial in preventing respiratory compromise and maintaining oxygenation. Choices A, C, and D are not the highest priority because they do not directly address the immediate risk to the client's physiological well-being. Treating disturbed body image, anxiety, or imbalanced nutrition are important but can be addressed after ensuring the client's airway is clear and they are able to breathe effectively.
When assessing a client with a disorder of the hematopoietic or the lymphatic, why is it important for the nurse to obtain a dietary history?
- A. Compromised nutrition interferes with the production of blood cells and hemoglobin
- B. Diet consisting of excessive fat interferes with the production of blood cells and haemoglobin
- C. Inconsistent dieting interferes with the production of blood cells and haemoglobin
- D. Diet consisting of excessive iron and protein elements interferes with the production of blood cells and haemoglobin
Correct Answer: A
Rationale: The correct answer is A because compromised nutrition can lead to deficiencies in essential nutrients required for the production of blood cells and hemoglobin. Iron, vitamins, and minerals obtained from food are crucial for erythropoiesis and maintaining a healthy immune system. Without these nutrients, the body may struggle to produce an adequate amount of healthy red blood cells, leading to anemia and compromised immune function.
Choice B is incorrect because excessive fat in the diet is not directly linked to interfering with the production of blood cells and hemoglobin. Choice C is incorrect as inconsistent dieting may affect overall health but is not specifically related to hematopoiesis. Choice D is incorrect because while iron and protein are important for blood cell production, excessive amounts of these elements are unlikely to interfere with the production of blood cells and hemoglobin.
For the first 72 hours thyroidectomy surgery, the nurse would assess the client for Chvostek’s sign and Trousseau’s sign because they indicate which of the following?
- A. Hypocalcamia
- B. hypokalemia
- C. Hypercalcemia
- D. Hyperkalemia
Correct Answer: A
Rationale: The correct answer is A: Hypocalcemia. Chvostek's sign and Trousseau's sign are both indicators of hypocalcemia, which is a common complication following thyroidectomy surgery due to potential damage to the parathyroid glands. Chvostek's sign is elicited by tapping the facial nerve and observing facial muscle twitching, while Trousseau's sign involves carpal spasm induced by inflating a blood pressure cuff above systolic pressure. Both signs are sensitive indicators of hypocalcemia due to their association with neuromuscular irritability. Hypercalcemia (option C) and hyperkalemia (option D) are not typically associated with thyroidectomy surgery and would not present with these specific signs. Hypokalemia (option B) is not related to Chvostek's sign and Trousseau's sign.