Nokea
A client diagnosed with metastatic cancer of the bone is exhibiting mental confusion and a BP of 160/100. Which laboratory value would correlate with the client's symptoms reflecting a common complication with this diagnosis?
- A. Potassium 5.2 mEq/l
- B. Calcium 13 mg/dl
- C. Inorganic phosphorus 1.7 mEq/l
- D. Sodium 138 mEq/l
Correct Answer: B
Rationale: Hypercalcemia is a common occurrence with cancer of the bone. The potassium level is elevated but does not relate to the diagnosis, so answer A is incorrect. Answers C and D are both normal levels, so they are incorrect.
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The nurse is caring for a client who has gastroesophageal reflux disease and has been receiving long-term omeprazole therapy. The nurse should recognize that the client is at highest risk for developing
- A. jaw necrosis
- B. vision changes
- C. gait disturbance
- D. Clostridoides difficile infection
Correct Answer: D
Rationale: Long-term omeprazole increases risk of C. difficile due to altered gut flora. Jaw necrosis , vision changes , and gait disturbance are not associated.
The nurse is to administer a tube feeding to a client. Before administering the feeding, what is essential for the nurse to do?
- A. Ask the client if she feels full
- B. Aspirate the nasogastric tube and check for acid
- C. Change the tubing
- D. Feel over the end of the tube and do not administer if air is felt
Correct Answer: B
Rationale: Aspirating and checking for acidic pH confirms nasogastric tube placement in the stomach, preventing aspiration. Other actions are irrelevant or unsafe.
An adult is almost ready for discharge. She has a complicated care regimen to follow. When conducting client teaching, the nurse notes that the client cannot recall basic information that was discussed the day before. The client also appears distracted. When asked if she is feeling comfortable about leaving the hospital, she states, 'There's just too much to learn. I know I'm going to get home and mess something up.' The nurse realizes that the client may be experiencing:
- A. mild anxiety.
- B. moderate anxiety.
- C. severe anxiety.
- D. panic anxiety.
Correct Answer: B
Rationale: Difficulty recalling information and expressed worry about managing care suggest moderate anxiety, impairing learning but not reaching panic.
The nurse in the emergency department is caring for a client who has a small piece of wood penetrating the right eye. Which of the following actions should the nurse take?
- A. Flush the eye
- B. Remove the object with tweezers.
- C. Stabilize the object.
- D. Administer optic antibiotic ointment.
Correct Answer: C
Rationale: Stabilizing the object prevents further damage until surgical removal. Flushing , removing , or applying ointment risks worsening the injury.
The nurse reinforces teaching about the use of the peak flow meter to evaluate airflow to a client newly diagnosed with asthma. Which statement by the client indicates an understanding of the nurse's teaching?
- A. I will exhale a complete breath as quickly as possible through the mouthpiece of the device to obtain a peak flow reading
- B. I will move the indicator to the desired reading on the numbered scale before using the device
- C. I will record the lowest of 3 consecutive peak flow readings in my asthma journal every day.
- D. I will remember to use the device after taking my fluticasone via metered-dose inhaler.
Correct Answer: A
Rationale: Exhaling quickly is the correct technique for peak flow. Setting the indicator , recording the lowest reading , and using post-inhaler are incorrect.