Nokea
A client is admitted for treatment of hypoparathyroidism. Based on the client's diagnosis, the nurse would anticipate an order for:
- A. Potassium
- B. Magnesium
- C. Calcium
- D. Iron
Correct Answer: C
Rationale: The parathyroid is responsible for calcium and phosphorus absorption. Clients with hypoparathyroidism have hypocalcemia. Answers A, B, and D are not associated with hypoparathyroidism; therefore, they are incorrect.
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A client who has Mycoplasma pneumonia needs to go to the radiology department for a chest x-ray. What should the client wear?
- A. A face shield
- B. A surgical mask
- C. An N95 respirator
- D. Gloves and a gown
Correct Answer: B
Rationale: A surgical mask prevents droplet transmission of Mycoplasma pneumonia during transport, protecting others.
While caring for a client in skeletal traction, which tasks can the nurse assign to experienced unlicensed assistive personnel to help prevent immobility hazards? Select all that apply.
- A. Assist with active and passive range of motion exercises
- B. Change bed linens while logrolling the client from side to side
- C. Check the color and temperature of the affected extremity
- D. Reapply pneumatic compression device after bathing the client
- E. Remind the client to use the incentive spirometer
Correct Answer: A,D,E
Rationale: Assisting with range of motion, reapplying compression devices, and reminding about spirometry are within UAP scope and prevent immobility issues. Assessing extremities and logrolling require nursing judgment.
The nurse is collecting data from a client with a history of alcohol use disorder who had an emergency appendectomy 3 days ago. Which of the following findings would indicate that the client is experiencing delirium tremens? Select all that apply.
- A. Bradypnea
- B. Diaphoresis
- C. Hallucinations
- D. Lethargy
- E. Tachycardia
Correct Answer: B,C,E
Rationale: Delirium tremens presents with diaphoresis, hallucinations, and tachycardia due to autonomic hyperactivity. Bradypnea and lethargy are not typical; agitation is more common.
A 4-month-old infant is being treated for talipes equinovarus (clubfoot). The nurse should include which of the following in the priority teaching plan for the parents?
- A. Monitor respiratory rate
- B. Monitor intake and output every hour
- C. Assist the client to breathe into a paper bag
- D. Prepare to administer oxygen by mask
Correct Answer: C
Rationale: Assisting the client to breathe into a paper bag addresses hyperventilation caused by aspirin toxicity, which can lead to respiratory alkalosis in the initial stages.
The nurse in the outpatient clinic is talking with a client who was diagnosed with hypertension 6 months ago. The client's current blood pressure is 170/94 mm Hg. Which of the following questions would be most important for the nurse to ask?
- A. Are you feeling overwhelmed at home or work?
- B. Can you describe your daily eating habits to me?
- C. Do you smoke cigarettes or use tobacco products?
- D. How often do you take your antihypertensive medications?
Correct Answer: D
Rationale: A major disadvantage of long-term management of hypertension is poor adherence to the treatment plan. Blood pressure medications can have unpleasant adverse effects, including fatigue, dizziness, and erectile dysfunction. In addition, clients may stop taking the medications when they believe their blood pressure has returned to normal range or if medications are expensive. Abrupt discontinuation of prescribed antihypertensive medications can lead to hypertensive crisis, a life-threatening emergency characterized by severely elevated blood pressure (ie, systolic ≥180 mm Hg and/or diastolic ≥120 mm Hg). To prevent complications (eg, end organ damage), the nurse should determine if the client has been taking the medications consistently (Option 4). There may be a need for a dosage change or addition of another medication.