Nokea
A client is being treated for acute low back pain. Which of these clinical manifestations must be reported to the physician immediately?
- A. Diffuse, aching sensation in the L4 to L5 area
- B. New onset of footdrop
- C. Pain in the lower back when the leg is lifted
- D. Pain in the lower back that radiates to the hip
Correct Answer: B
Rationale: New onset footdrop indicates possible nerve compression or damage, requiring immediate reporting to prevent permanent impairment. Other symptoms are common in low back pain and less urgent.
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Which of the following is appropriate for a client with metabolic alkalosis?
- A. Monitor serum potassium levels
- B. Maintain the client on bed rest
- C. Have the client inhale carbon dioxide using a paper bag
- D. Administer sodium bicarbonate as ordered
Correct Answer: A
Rationale: Metabolic alkalosis can cause hypokalemia, so monitoring serum potassium levels is appropriate. Bed rest is not indicated, inhaling CO2 is for respiratory alkalosis, and sodium bicarbonate would worsen alkalosis.
The mother of a 3-year-old child tells the nurse her child is 'fussy' and not as 'easy going' as her other children. She is having difficulty feeding the child because he fusses and cries when she serves a meal. The nurse should instruct the mother to:
- A. Allow the child to determine when feeding should occur.
- B. Not to feed the child if he cries.
- C. Provide structured feeding times and routines.
- D. Give the child finger foods and let him eat when he wants.
Correct Answer: C
Rationale: Structured feeding times and routines help establish consistent eating habits, reducing fussiness by providing predictability for the child.
The nurse is teaching a client how to mix regular and NPH insulins in the same syringe. Which action should the nurse instruct the client to take?
- A. Draw up the NPH insulin into the syringe first.
- B. Keep both bottles in the refrigerator at all times.
- C. Rotate the NPH insulin bottle in the hands before mixing.
- D. Take all of the air out of the insulin bottles before mixing.
Correct Answer: C
Rationale: The NPH insulin bottle needs to be rotated for at least 1 minute between both hands. This resuspends the insulin. The nurse should not shake the bottles. Shaking causes foaming and bubbles to form, which may trap particles of insulin and alter the dosage. Regular insulin is drawn up before NPH insulin. Insulin may be maintained at room temperature. Additional bottles of insulin for future use should be stored in the refrigerator. Air does not need to be removed from the insulin bottles.
A young adult is hospitalized with a seizure disorder. The client, who is in a bed with padded side rails, has a tonic-clonic seizure. In what order should the nurse take the following actions?
- A. Loosen clothing around the client's neck.
- B. Turn the client on his or her side.
- C. Clear the area around the client.
- D. Suction the airway.
Correct Answer: C,B,A,D
Rationale: First, clear the area to prevent injury, turn the client on their side to maintain airway patency, loosen clothing to ease breathing, and suction if needed to clear secretions.
A client with a history of cirrhosis is prescribed propranolol (Inderal). The nurse should monitor the client for which of the following therapeutic effects?
- A. Decreased portal hypertension.
- B. Increased blood glucose.
- C. Decreased ammonia levels.
- D. Increased platelet count.
Correct Answer: A
Rationale: Propranolol reduces portal hypertension by decreasing portal vein pressure in cirrhosis.