Nokea
A client is admitted with diabetic ketoacidosis (DKA). Which laboratory finding requires immediate intervention by the nurse?
- A. Blood glucose of 450 mg/dL
- B. Potassium level of 4.0 mEq/L
- C. PaO2 of 92 mmHg
- D. HCT of 60
Correct Answer: C
Rationale: This high hematocrit is indicative of severe dehydration which requires priority attention in diabetic ketoacidosis. Without sufficient hydration, all systems of the body are at risk for hypoxia from a lack of or sluggish circulation.
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Which of the following drugs should the nurse anticipate administering to a client before they are to receive electroconvulsive therapy?
- A. Benzodiazepines
- B. Chlorpromazine (Thorazine)
- C. Succinylcholine (Anectine)
Correct Answer: C
Rationale: Succinylcholine (Anectine). Succinylcholine is given intravenously to promote skeletal muscle relaxation.
All of the following need to be done. Which should the nurse do first?
- A. A client who had surgery earlier today asks for pain medication.
- B. A client who is two days postoperative needs a dressing change.
- C. A client who had a cerebrovascular accident needs a bed bath.
- D. A client scheduled for surgery tomorrow needs an enema.
Correct Answer: A
Rationale: Pain management for a client post-surgery today is a priority to promote comfort and recovery. Dressing changes, bed baths, and preoperative enemas are less urgent.
A transfusion is ordered for a hospitalized client. The charge nurse asks the LPN to start the transfusion. What should the LPN do?
- A. Start the transfusion as ordered
- B. Be sure that dextrose is hanging and then hang the blood
- C. Tell the RN that LPNs are not allowed to hang blood
- D. Hang the blood only if an IV line is already established
Correct Answer: C
Rationale: LPNs typically cannot initiate blood transfusions due to scope of practice limitations, as it requires specialized monitoring, so the LPN should inform the RN.
The nurse is reinforcing information for a client with chronic obstructive pulmonary disease. Which statements by the client indicate an understanding of the pursed-lip breathing technique? Select all that apply.
- A. I exhale for 2 seconds through pursed lips
- B. I exhale for 4 seconds through pursed lips
- C. I inhale for 2 seconds through my mouth
- D. I inhale for 2 seconds through my nose, keeping my mouth closed
- E. I inhale for 4 seconds through my nose, keeping my mouth closed
Correct Answer: B,D
Rationale: Pursed-lip breathing involves inhaling 2 seconds through the nose (mouth closed) and exhaling 4 seconds through pursed lips to prolong exhalation and reduce air trapping in COPD.
A client is brought to the emergency room with injuries sustained in an auto accident. While performing his assessment, the nurse notes the presence of Cullen's sign. Cullen's sign is suggestive of:
- A. A neurological injury
- B. A ruptured spleen
- C. A bowel perforation
- D. Retroperitoneal bleeding
Correct Answer: D
Rationale: Cullen's sign, a bluish discoloration around the umbilicus, indicates retroperitoneal or intra-abdominal bleeding, often due to trauma or conditions like pancreatitis. It is not specific to neurological injury, spleen rupture, or bowel perforation.