Nokea
When caring for a client with acute renal failure, which laboratory value is most important to monitor?
- A. Serum sodium
- B. Serum potassium
- C. Serum calcium
- D. Serum chloride
Correct Answer: B
Rationale: The correct answer is B: Serum potassium. In acute renal failure, impaired kidney function can lead to electrolyte imbalances, especially hyperkalemia which can be life-threatening. Monitoring serum potassium levels is crucial to prevent cardiac complications. Serum sodium (A) may be altered, but potassium is more critical. Serum calcium (C) and chloride (D) levels are important but not as directly impacted in acute renal failure compared to potassium.
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A client has a pulmonary embolism & is started on oxygen. The student nurse asks why the client's oxygen saturation has not significantly improved. What response by the nurse is best?
- A. Breathing so rapidly interferes with oxygenation.
- B. Maybe the client has respiratory distress syndrome.
- C. The blood clot interferes with perfusion in the lungs.
- D. The client needs immediate intubation & mechanical ventilation.
Correct Answer: C
Rationale: Correct Answer: C
Rationale:
1. A pulmonary embolism is a blockage in one of the pulmonary arteries, affecting blood flow to the lungs.
2. This blockage limits perfusion, the process of blood flow through the lungs for oxygenation.
3. Oxygen saturation may not improve significantly because the blood clot interferes with perfusion, not ventilation.
4. Options A and B focus on ventilation issues, which may not be the primary concern in this case.
5. Option D is extreme and not supported by the information given about the client's condition.
Summary:
Choice C is correct because a pulmonary embolism affects perfusion in the lungs, leading to decreased oxygen saturation. Choices A, B, and D are incorrect as they focus on other issues not directly related to the client's condition.
After an open lung biopsy, a nurse assesses a client. Which assessment finding is matched with the correct intervention?
- A. Client states he is dizzy. Nurse applies oxygen and pulse oximetry.
- B. Client's HR is 55 beats/min. Nurse withholds pain medication.
- C. Client has reduced breath sounds. Nurse calls the physician immediately.
- D. Client's RR is 18 breaths/min. Nurse decreases the oxygen flow rate.
Correct Answer: C
Rationale: The correct answer is C because reduced breath sounds after an open lung biopsy could indicate a potential complication like pneumothorax. In this situation, it is crucial for the nurse to call the physician immediately for further assessment and intervention. This prompt action can help prevent worsening of the client's condition and ensure timely treatment.
Choice A is incorrect because applying oxygen and pulse oximetry is not directly addressing the potential complication of reduced breath sounds. Choice B is incorrect because withholding pain medication based solely on a low heart rate is not appropriate without further assessment. Choice D is incorrect because decreasing oxygen flow rate without proper assessment could be harmful if the client is experiencing respiratory distress.
A 54-year-old client has cholelithiasis and is admitted for an elective cholecystectomy. The client is 5 feet 3 inches tall, weighs 205 pounds, and has smoked one pack of cigarettes per day for 35 years. The client will be NPO at midnight. When the client's spouse asks why the client cannot have breakfast the morning before surgery, the nurse should explain:
- A. Your spouse is a good-sized person and it won't hurt to miss breakfast.
- B. Eating breakfast and having food in the stomach could cause vomiting and aspiration during surgery.
- C. Your spouse will be too busy in the morning preparing for surgery to have time to eat breakfast.
- D. Not eating breakfast will prevent fecal contamination of the abdominal operative site.
Correct Answer: B
Rationale: The client's size has nothing to do with an NPO status. Clients are at greatest risk for aspiration and vomiting during surgery when food and/or liquids are in the stomach. Preparation on the morning of surgery is time consuming, but it does not affect a client's NPO status. The gallbladder lies under the surface of the liver and is a part of the biliary tract, not the intestinal tract. Cholecystectomy does not involve the intestinal tract or its contents.
What correctly describes pursed-lip breathing?
- A. Breathe in to count of 4 and out to count of 2, pursing lips
- B. Breathe in through nose and slowly exhale through pursed lips
- C. Place one hand on abdomen and other on chest, inhaling through pursed lips and exerting pressure on inspiration
- D. Take in a deep breath, through pursed lips, then let out one-third; continue this pattern
Correct Answer: B
Rationale: Pursed-lip breathing involves slow exhalation to prolong expiration and improve airflow.
You have been pulled to the telemetry unit for the day. The monitor watcher informs you that the client has developed prominent U waves. Which laboratory value should you check immediately?
- A. Sodium
- B. Potassium
- C. Magnesium
- D. Calcium
Correct Answer: B
Rationale: Prominent U waves on an ECG strip are typically associated with hypokalemia (low potassium levels). Checking potassium levels is critical to address potential cardiac complications.