Nokea
A client has been taking lithium 300 mg po bid for the past two weeks. This morning her lithium level was 1 mEq/L. The nurse should:
- A. Notify the physician immediately
- B. Hold the morning lithium dose and continue to observe the client
- C. Administer the morning lithium dose as scheduled
- D. Obtain an order for benztropine (Cogentin)
Correct Answer: C
Rationale: There is no need to phone the physician because the lithium level is within therapeutic range and because there are no indications of toxicity present. There is no reason to withhold the lithium because the blood level is within therapeutic range. Also, it is necessary to give the medication as scheduled to maintain adequate blood levels. The lab results indicate that the client's lithium level is within therapeutic range (0.2-1.4 mEq/L), so the medication should be given as ordered. Benztropine is an antiparkinsonism drug frequently given to counteract extrapyramidal symptoms associated with the administration of antipsychotic drugs (not lithium).
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Which diet would the nurse expect to see ordered for a patient with nephrotic syndrome?
- A. Low carbohydrate potassium
- B. Moderate protein
- C. Low calcium
- D. Increased potassium
Correct Answer: B
Rationale: Nephrotic syndrome causes proteinuria, leading to hypoalbuminemia. A moderate protein diet (0.8–1 g/kg/day) helps replace lost protein without overloading the kidneys. Low carbohydrate, low calcium, or increased potassium diets are not specific to nephrotic syndrome.
A client is hyperactive and not sleeping. She will not remain at the table during mealtime. She is getting very limited calories and is using a lot of energy in her hyperactive state. The most therapeutic nursing action is to:
- A. Insist that she remain at the table and eat a balanced diet.
- B. Order a high-calorie diet with supplements.
- C. Provide nutritious finger foods several times a day.
- D. Offer to go to the dining room with her and allow her to open the food and inspect what she eats.
Correct Answer: C
Rationale: Providing finger foods increases the likelihood of eating for hyperactive persons. They may be eating 'on the run,' accommodating their high energy state.
An 18-month-old is admitted to the hospital with acute laryngotracheobronchitis. When assessing the respiratory status, the nurse should expect to find:
- A. Inspiratory stridor and harsh cough
- B. Strident cough and drooling
- C. Wheezing and intercostal retractions
- D. Expiratory wheezing and nonproductive cough
Correct Answer: A
Rationale: Acute laryngotracheobronchitis (croup) typically presents with inspiratory stridor and a harsh, barking cough due to subglottic airway inflammation.
The nurse is caring for a client with a history of a pneumothorax who is being discharged. The nurse should teach the client to:
- A. Resume heavy lifting
- B. Avoid swimming
- C. Report chest pain immediately
- D. Sleep on the affected side
Correct Answer: C
Rationale: Chest pain post-pneumothorax may indicate recurrence or complications, requiring immediate reporting. Heavy lifting and swimming are restricted, and sleeping position is not critical.
Assessment of parturient reveals the following: cervical dilation 6 cm and station 22; no progress in the last 4 hours. Uterine contractions decreasing in frequency and intensity. Marked molding of the presenting fetal head is described. The physician orders, 'Begin oxytocin induction at 1 mU/min.' The nurse should:
- A. Begin the oxytocin induction as ordered
- B. Increase the dosage by 2 mU/min increments at 15-minute intervals
- C. Maintain the dosage when duration of contractions is 40-60 seconds and frequency is at 2-1/2-4 minute intervals
- D. Question the order
Correct Answer: D
Rationale: Oxytocin stimulates labor but should not be used until CPD (cephalopelvic disproportion) is ruled out in a dysfunctional labor. This answer is the correct protocol for oxytocin administration, but the medication should not be used until CPD is ruled out. This answer is the correct manner to interpret effective stimulation, but oxytocin should not be used until CPD is ruled out. This answer is the appropriate nursing action because the scenario presents a dysfunctional labor pattern that may be caused by CPD. Oxytocin administration is contraindicated in CPD.