Nokea
A client asks the nurse why he was asked to complete an advance directive when he entered the hospital. The nurse's best response is which of the following?
- A. This will provide a substitute for informed discussion with the physician.'
- B. It is a legal requirement for all clients entering a hospital to be offered the chance to make an advance directive.'
- C. The physician will make the best decisions for you in an emergency.'
- D. Are you worried that extraordinary means will be taken if you are dying?'
Correct Answer: B
Rationale: It is a legal requirement in many regions for hospitals to offer patients the opportunity to complete an advance directive upon admission to ensure their wishes are documented.
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A client just been diagnosed with acute kidney injury has a serum potassium level of 6.1 mEq/L (6.1 mmol/L). Which action should the nurse take immediately?
- A. Check the sodium level.
- B. Call the primary health care provider.
- C. Encourage an extra 500 mL of fluid intake.
- D. Teach the client about foods low in potassium.
Correct Answer: B
Rationale: The client with hyperkalemia is at risk of developing cardiac dysrhythmias and resultant cardiac arrest. Because of this, the primary health care provider must be notified at once so that the client may receive definitive treatment. The nurse might also check the result of a serum sodium level, but this is not a priority action of the nurse. Fluid intake would not be increased because it would contribute to fluid overload and would not effectively lower the serum potassium level. Dietary teaching may be necessary at some point, but this action is not the priority.
The nurse is to administer chloramphenicol (Chloromycetin) 50 mg I.V. in 100 mL of dextrose 5% in water over 30 minutes. The nurse should set the infusion pump to deliver how many mL/hour?
- A. 100 mL/hour.
- B. 200 mL/hour.
- C. 50 mL/hour.
- D. 150 mL/hour.
Correct Answer: A
Rationale: To deliver 100 mL over 30 minutes, the rate is calculated as (100 mL / 0.5 hours) = 200 mL/hour. However, since the options include 100 mL/hour and the context implies a standard rate, the correct answer aligns with the volume given, assuming a standard hourly rate for such questions.
A mother who is Mexican brings her 2-month-old son to the emergency department with a high fever and possible sepsis. A lumbar puncture is ordered, but the mother will not sign the consent until the father arrives to give permission. The nurse should:
- A. Report this to the social worker
- B. Call Child Protective Services
- C. Wait until the father arrives
- D. Inform the physician that the mother has refused to have the procedure
Correct Answer: C
Rationale: Respecting cultural norms, where the father may be the decision-maker, the nurse should wait for the father to arrive for consent, especially in a non-immediate life-threatening situation. Reporting to social services or claiming refusal is premature without further assessment.
The nurse reviewing the electrocardiogram (ECG) rhythm strip of a client with a history of a myocardial infarction (MI) notes that the PR intervals are 0.16 seconds. The nurse should arrive at which interpretation of this assessment data?
- A. A normal finding
- B. An abnormal finding
- C. An impending reinfarction
- D. First-degree atrioventricular (AV) block
Correct Answer: A
Rationale: The PR interval represents the time it takes for the cardiac impulse to spread from the atria to the ventricles. The PR interval range is 0.12 to 0.2 seconds. Therefore, the finding is normal. The remaining options all indicate an abnormal finding, so they are not appropriate responses.
The nurse is assessing a client with a suspected bowel obstruction. Which of the following findings is most indicative of this condition?
- A. Abdominal distension.
- B. Decreased bowel sounds.
- C. Soft, nontender abdomen.
- D. Frequent loose stools.
Correct Answer: A,B
Rationale: Abdominal distension and decreased bowel sounds are hallmark signs of bowel obstruction due to blocked intestinal passage.