Nokea
A client admitted with gastroenteritis and a potassium level of 2.9 mEq/dL has been placed on telemetry. Which ECG finding would the nurse expect to find due to the client's potassium results?
- A. A depressed ST segment
- B. An elevated T wave
- C. An absent P wave
- D. A flattened QRS
Correct Answer: A
Rationale: Hypokalemia (2.9 mEq/dL) can cause a depressed ST segment, flattened T waves, and prominent U waves on ECG due to altered cardiac repolarization.
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A preterm infant with sepsis is receiving Gentamycin (garamycin). Which physiological alteration places the preterm infant at increased risk for toxicity related to aminoglycoside therapy?
- A. Lack of subcutaneous fat deposits
- B. Immature central nervous system
- C. Presence of fetal hemoglobin
- D. Immaturity of the renal system
Correct Answer: D
Rationale: The immature renal system in preterm infants reduces the ability to excrete aminoglycosides like Gentamycin, increasing the risk of toxicity.
Which of the following is a core measure set developed by the Joint Commission?
- A. genetics
- B. lymphoma
- C. nosocomial infections
- D. heart failure
Correct Answer: D
Rationale: Heart failure is a Joint Commission core measure set, focusing on improving care quality for common conditions. The others are not core measures.
The client is admitted following cast application for a fractured ulna. Which finding should be reported to the doctor?
- A. Pain at the site
- B. Warm fingers
- C. Pulses rapid
- D. Paresthesia of the fingers
Correct Answer: D
Rationale: Paresthesia of the fingers suggests possible nerve compression or compartment syndrome, which requires immediate reporting to the doctor.
A client with COPD is in respiratory failure. Which of the following results would be the most sensitive indicator that the client requires a mechanical ventilator?
- A. PCO2 58
- B. SaO2 90
- C. PH 7.23
- D. HCO3 30
Correct Answer: C
Rationale: A pH of 7.23 indicates severe respiratory acidosis due to CO2 retention, a sensitive indicator for mechanical ventilation need in COPD. PCO2 and HCO3 are less immediate, and SaO2 is not critical.
A client with sickle cell anemia is admitted to the labor and delivery unit during the first phase of labor. The nurse should anticipate the client's need for:
- A. Supplemental oxygen
- B. Fluid restriction
- C. Blood transfusion
- D. Delivery by Caesarean section
Correct Answer: A
Rationale: Sickle cell anemia increases oxygen demand during labor, often requiring supplemental oxygen.