Nokea
A client has experienced 48 hours of severe repeated bouts of vomiting. Which acid-base imbalance is of most concern?
- A. Respiratory acidosis
- B. Respiratory alkalosis
- C. Metabolic acidosis
- D. Metabolic alkalosis
Correct Answer: D
Rationale: Severe vomiting causes loss of gastric acid, leading to metabolic alkalosis (D). Respiratory imbalances (A, B) and metabolic acidosis (C) are less likely.
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The physician has ordered a low-residue diet for a client with Crohn's disease. Which food is not permitted in a low-residue diet?
- A. Mashed potatoes
- B. Smooth peanut butter
- C. Fried fish
- D. Rice
Correct Answer: C
Rationale: Fried fish is high in fat and residue, which can exacerbate symptoms in Crohn's disease; low-residue diets emphasize easily digestible foods.
The client with preeclampsia is admitted to the unit with an order for magnesium sulfate IV. Which action by the nurse indicates a lack of understanding of magnesium sulfate?
- A. The nurse places a sign over the bed not to check blood pressures in the left arm.
- B. The nurse obtains an IV controller.
- C. The nurse inserts a Foley catheter.
- D. The nurse darkens the room.
Correct Answer: A
Rationale: Avoiding blood pressure checks in one arm is unrelated to magnesium sulfate; the other actions align with monitoring and managing side effects.
The nurse recognizes all of the following as part of the Cushing reflex triad EXCEPT
- A. cardiac arrhythmia.
- B. increased blood pressure.
- C. irregular respirations.
- D. decreased heart rate.
Correct Answer: A
Rationale: Cushing reflex (response to increased intracranial pressure) includes hypertension, bradycardia, and irregular respirations. Cardiac arrhythmia is not part of the triad.
The nurse has just administered an IM injection to a client. In which of the following ways should the nurse dispose of the needle?
- A. re-cap the needle and discard it in the nearest puncture-resistant container
- B. break the needle and discard it in the nearest puncture-resistant container
- C. discard the needle in a puncture-resistant container in the central medication area
- D. discard the needle in a puncture-resistant container in the client's room
Correct Answer: D
Rationale: Needles should be disposed of immediately in a puncture-resistant container in the client’s room to minimize sharps injury risk.
The nurse finds a client smoking marijuana in the hospital and tells her that no smoking or use of drugs is allowed in the facility. The client responds by shouting, 'What business is it of yours? Leave me alone!' Which of the following initial responses is the best for the nurse to use to defuse the situation?
- A. It's my business because I'm your nurse.'
- B. If you don't put that out immediately, I will call security.'
- C. You are violating the facility policies and the law!'
- D. I'm sorry, but I have to ask you again to put out your marijuana cigarette.'
Correct Answer: D
Rationale: A calm, polite request to stop (D) de-escalates the situation while reinforcing the rule. Other responses (A, B, C) are confrontational and likely to escalate the client's agitation.