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A client in acute renal failure has a serum potassium of 7.5 mEq/L. Based on this finding, the nurse should anticipate implementing which action?
- A. Administer an IV of normal saline rapidly and NPH insulin subcutaneously.
- B. Administer a retention enema of Kayexalate.
- C. Add 40 mEq of KCL (potassium chloride) to the present IV solution.
- D. Administer a lidocaine bolus IV push.
Correct Answer: B
Rationale: In acute renal failure with a high serum potassium level, the priority intervention is to lower potassium levels to prevent complications like cardiac arrhythmias. Administering a retention enema of Kayexalate is the correct action as it helps lower high potassium levels by exchanging sodium for potassium in the intestines. Options A, C, and D are incorrect. Administering normal saline rapidly and NPH insulin or adding more potassium to the IV solution can further increase potassium levels, worsening the condition. Lidocaine is not indicated for treating hyperkalemia.
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A male client is admitted to the mental health unit because he experiences panic attacks when driving on the freeway. To attempt to desensitize this fear, what action should the nurse encourage the client to implement?
- A. Watch training videos of people driving in various environments
- B. Begin visualizing himself driving each route to the freeway
- C. Take antianxiety medication two hours before driving on freeways
- D. Get in the car with a support person and drive on a freeway during rush hour
Correct Answer: B
Rationale: Visualization techniques, such as visualizing himself driving each route to the freeway, are commonly used in desensitization therapy to help clients gradually overcome their fears. Watching videos of others driving or taking medication do not actively involve the client in facing their fear, which is essential in desensitization therapy. Getting in the car with a support person during rush hour may exacerbate the client's anxiety rather than help in desensitization.
A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen at 4 liters per minute via nasal cannula. The client becomes lethargic and confused. What action should the nurse take first?
- A. Decrease the oxygen flow rate
- B. Increase the oxygen flow rate
- C. Encourage the client to cough and deep breathe
- D. Monitor the client's oxygen saturation level
Correct Answer: A
Rationale: In this scenario, the priority action for the nurse is to decrease the oxygen flow rate. Clients with COPD are sensitive to high levels of oxygen and can develop oxygen toxicity, leading to symptoms like lethargy and confusion. Decreasing the oxygen flow rate helps prevent this complication. Increasing the oxygen flow rate would worsen the client's condition. Encouraging coughing and deep breathing may not address the immediate issue of oxygen toxicity. While monitoring the client's oxygen saturation level is important, taking action to address the oxygen toxicity by decreasing the flow rate is the priority in this situation.
The healthcare provider prescribes a diet high in vitamin C for a client with a leg wound. Which food should the nurse encourage the client to eat?
- A. Bananas and pineapple
- B. Cottage cheese and crackers
- C. Peanut butter and jelly
- D. Tomato and lettuce salad
Correct Answer: D
Rationale: Tomatoes and lettuce are high in vitamin C, making them suitable choices for a diet prescribed for wound healing. Bananas and pineapple (Choice A) are not particularly high in vitamin C compared to tomatoes and lettuce. Cottage cheese and crackers (Choice B) as well as peanut butter and jelly (Choice C) do not provide significant amounts of vitamin C, which is essential for wound healing.
The nurse is caring for a client who is receiving total parenteral nutrition (TPN) via a central venous catheter. Which assessment finding indicates a complication related to the TPN?
- A. Blood glucose level of 180 mg/dl
- B. Serum potassium level of 4.0 mEq/L
- C. Weight gain of 2 pounds in 24 hours
- D. White blood cell count of 7000/mm3
Correct Answer: C
Rationale: A weight gain of 2 pounds in 24 hours is concerning as it indicates fluid retention, a potential complication of TPN leading to fluid overload. Elevated blood glucose levels (Choice A) are expected in TPN, serum potassium levels (Choice B) are within the normal range, and a white blood cell count (Choice D) of 7000/mm3 is also normal. Therefore, the correct answer is C, as it suggests a complication related to TPN.
A 20-year-old male client is diagnosed with Ewing's sarcoma following examination for a knee injury. Which instruction is most important for the nurse to provide the client?
- A. Take analgesics regularly to reduce the pain
- B. Notify the healthcare provider if the swelling worsens
- C. Avoid weight-bearing until the injury heals
- D. Seek treatment for the sarcoma immediately
Correct Answer: D
Rationale: The correct answer is to instruct the client to seek treatment for the sarcoma immediately. Ewing's sarcoma is an aggressive cancer, and prompt treatment is crucial for improving prognosis. Option A is incorrect because while pain management is important, addressing the underlying cause (sarcoma) is the priority. Option B is not as critical as seeking treatment for the sarcoma itself. Option C is not the most important instruction as the primary concern is addressing the cancer diagnosis.