Nokea
A client has renal failure. Today's lab values indicate he has an elevated serum potassium. What additional priority information does the nurse need to obtain?
- A. Evaluation of his level of consciousness
- B. Evaluation of an electrocardiogram
- C. Measurement of his urine output for the past 8 hours
- D. Serum potassium lab values for the last several days
Correct Answer: B
Rationale: The level of consciousness is not affected by elevated potassium levels. An electrocardiogram (EKG) can tell the nurse whether this client is experiencing any cardiac dysfunction or arrhythmias related to the elevated potassium level. Measurement of the urine output is not a priority nursing action at this time. The client's serum potassium values for the past several days may provide information about his renal function, but they are not a priority at this time.
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Place in correct sequence the steps from 1-7 used when performing tracheostomy suctioning.
- A. Suction the oral cavity.
- B. Auscultate breath sounds for effectiveness.
- C. Set suction control at 80-120 mm Hg.
- D. Ambu or oxygenate at 100% O2
- E. Apply suction while withdrawing the suction catheter.
- F. Turn the head toward the side to be suctioned.
- G. Auscultate breath sounds prior to suctioning.
Correct Answer: G, C, D, F, E, B, A
Rationale: Sequence: Auscultate breath sounds (G), set suction pressure (C), oxygenate (D), turn head (F), apply suction (E), auscultate post-suction (B), suction oral cavity (A) to clean.
The nurse is caring for a client with a history of a hysterectomy. The client complains of hot flashes. The nurse should:
- A. Apply a heating pad
- B. Encourage fluid restriction
- C. Discuss hormone replacement therapy
- D. Administer acetaminophen
Correct Answer: C
Rationale: Hot flashes post-hysterectomy are due to hormonal changes. Discussing hormone replacement therapy with the physician is appropriate. Heating pads, fluid restriction, and acetaminophen are ineffective.
The nurse is caring for a child in a plaster-of-Paris hip spica cast. To facilitate drying, the nurse should:
- A. Use a small hand-held hair dryer set on medium heat.
- B. Place a small heater near the child's bed.
- C. Turn the child at least every two hours.
- D. Allow one side to dry before changing positions.
Correct Answer: C
Rationale: Turning the child every two hours ensures even drying of the cast and prevents pressure sores, promoting proper cast setting.
A 30-year-old client in the third trimester of her pregnancy asks the nurse for advice about upper respiratory discomforts. She complains of nasal stuffiness and epistaxis, most noticeable on the left side. Which reply by the nurse is correct?
- A. It sounds as though you are coming down with a bad cold. I'll ask the doctor to prescribe a decongestant for relief of symptoms.'
- B. A good vaporizer will help; avoid the cool air kind. Also, try saline nose drops, and spend less time on your left side.'
- C. These discomforts are all a result of increased blood supply; one of the pregnancy hormones, estrogen, causes them.'
- D. This is most unusual. I'm sure your obstetrician will want you to see an ENT (ear, nose, throat) specialist.'
Correct Answer: C
Rationale: Decongestants may exaggerate the nasal stuffiness associated with pregnancy. Judicious use of decongestants and nasal sprays is advocated during pregnancy. Cool air vaporizers and saline drops may help to relieve the nasal stuffiness. Positioning on either lateral side does not decrease nasal stuffiness or prevent epistaxis. Increased estrogen levels result in nasal mucosa edema with subsequent nasal stuffiness. Estrogen also promotes vasodilation, which contributes to epistaxis. The nurse may recommend cool air vaporizers and saline drops to help with the nasal stuffiness. Increased estrogen levels result in nasal mucosa edema with subsequent nasal stuffiness. Estrogen also promotes vasodilation discomforts associated with pregnancy.
A five-month-old infant is admitted to the ER with a temperature of 103.6°F and irritability. The mother states that the child has been listless for the past several hours and that he had a seizure on the way to the hospital. A lumbar puncture confirms a diagnosis of bacterial meningitis. The nurse should assess the infant for:
- A. Periorbital edema
- B. Tenseness of the anterior fontanel
- C. Positive Babinski reflex
- D. Negative scarf sign
Correct Answer: B
Rationale: Tenseness of the anterior fontanel indicates increased intracranial pressure in bacterial meningitis due to inflammation. The other findings are not specific to meningitis in infants.