Nokea
A client has been receiving lithium (Lithane) for the past two weeks for the treatment of bipolar illness. When planning client teaching, what is most important for the nurse to emphasize?
- A. Maintain a low sodium diet
- B. Take a diuretic with lithium and avoid excessive fluids
- C. Don't be overly concerned if feelings of depression occur
- D. Come in for evaluation of serum lithium levels regularly
Correct Answer: D
Rationale: Come in for evaluation of serum lithium levels regularly. Regular monitoring prevents toxicity, especially during conditions like hot weather that affect sodium levels.
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Before administering calcium gluconate 10% 500 mg IV stat.
It is MOST important that the nurse assess the
- A. stability of the respiratory system.
- B. adequacy of urine output.
- C. patency of the vein.
- D. availability of magnesium sulfate injection.
Correct Answer: C
Rationale: Strategy: Determine how each answer choice relates to calcium gluconate. (1) unnecessary in this situation (2) unnecessary in this situation (3) correct-if injected into the extravascular tissues, calcium gluconate can cause a severe chemical burn (4) irrelevant
When caring for an abused client, what is most important for the nurse to do initially?
- A. Provide a safe place for the victim
- B. Refer the victim to a long-term support group
- C. Make an appointment with a counselor
- D. Make arrangements for the victim to confront the abuser
Correct Answer: A
Rationale: Providing a safe place is the priority, ensuring immediate protection from further abuse before addressing long-term support.
An adult is admitted with probable pulmonary tuberculosis. Which findings would the nurse expect to be present in this client? Select all that apply.
- A. High fevers in the morning
- B. Cough
- C. Bloody sputum
- D. Night sweats
- E. Weight gain
- F. Malaise
Correct Answer: B,C,D,F
Rationale: Tuberculosis causes chronic cough, hemoptysis (bloody sputum), night sweats, and malaise due to systemic infection. Fevers are typically low-grade and nocturnal, and weight loss, not gain, is common.
A young adult patient constantly seeks attention from the nurses, stomping away from the nurses’ station and pouting when her requests are refused.
- A. What is the most appropriate response by the nurse to a young adult patient exhibiting attention-seeking behavior?
- B. Have the patient establish trust with one staff person with whom therapeutic interventions should occur.
- C. Give the patient unsolicited attention when she is not exhibiting the unacceptable behaviors.
- D. Ignore the patient when she exhibits attention-seeking behavior.
- E. Rotate the staff so the patient will learn to relate to more than one nurse.
Correct Answer: B
Rationale: Rewarding non-attention-seeking behaviors with unsolicited attention reinforces positive behavior. Ignoring the patient or rotating staff does not address the behavior constructively, and assigning one staff member reduces consistency in approach.
The nurse is caring for a client who is receiving a continuous IV infusion of midazolam (Versed) for sedation. Which of the following findings should the nurse report immediately?
- A. Respiratory rate of 12 breaths/min
- B. Blood pressure of 100/60 mmHg
- C. Heart rate of 80 bpm
- D. Oxygen saturation of 90%
Correct Answer: D
Rationale: An oxygen saturation of 90% indicates hypoxemia, a serious midazolam side effect. Options A, B, and C are acceptable: respiratory rate is low but stable, BP is mildly low, and heart rate is normal.