Nokea
A client is experiencing muscle weakness and lethargy. His serum K+ is 3.2. What other symptoms might he exhibit?
- A. Tetany
- B. Dysrhythmias
- C. Numbness of extremities
- D. Headache
Correct Answer: B
Rationale: Low potassium (3.2) causes dysrhythmias due to its role in cardiac muscle activity. The other symptoms are not associated with hypokalemia.
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A 65-year-old client is admitted after a stroke. Which nursing intervention would best improve tissue perfusion to prevent skin problems?
- A. Assessing the skin daily for breakdown
- B. Massaging any erythematous areas on the skin
- C. Changing incontinence pads as soon as they become soiled with urine or feces
- D. Performing range-of-motion exercises and turning and repositioning the client
Correct Answer: D
Rationale: Performing range-of-motion exercises and turning/repositioning enhances blood flow to tissues, reducing the risk of pressure ulcers by relieving pressure points. Assessing skin (A) is monitoring, not an intervention to improve perfusion. Massaging erythematous areas (B) can worsen tissue damage. Changing pads (C) prevents irritation but doesn’t directly improve perfusion.
The nurse is caring for a patient hospitalized with leukopenia. Which of the following assessments should be reported to the physician immediately?
- A. The blood pressure is 110/62.
- B. The apical pulse is 90.
- C. The temperature has increased from 98.6°F to 99.8°F.
- D. The respiratory rate is 24.
Correct Answer: C
Rationale: A temperature increase to 99.8°F in a patient with leukopenia (low white blood cell count) may indicate an infection which is a medical emergency due to the patient’s compromised immune system. The other vital signs are within normal limits and less urgent.
A seventh grader lost consciousness after being hit in the head with a basketball. In the emergency room his vital signs are stable, and he demonstrates no neurologic deficit. He will not be admitted to the hospital. It is most important that you advise his mother to:
- A. Encourage him to drink plenty of fluids
- B. Expect him to have nausea with vomiting
- C. Keep him awake for the next 12 hours
- D. Wake him up every 1-2 hours during the night
Correct Answer: D
Rationale: If the child cannot be awakened from sleep after head injury, it is an indication of serious increase in ICP. The mother should call an ambulance right away.
A female client decides on hemodialysis. She has an internal vascular access device placed. To ensure patency of the device, the nurse must:
- A. Assess the site for leakage of blood or fluids
- B. Auscultate the site for a bruit
- C. Assess the site for bruising or hematoma
- D. Inspect the site for color, warmth, and sensation
Correct Answer: B
Rationale: This is an internal device. Assessment of the site should include assessing for swelling, pain, warmth, and discoloration. This measure does not assess patency. The presence of a bruit indicates good blood flow through the device. The nurse should inspect the site for bruising or hematoma; however, this measure does not assure patency of the device. The nurse should inspect the vascular access site frequently for signs of infection. However, this does not assure patency.
The doctor has prescribed aspirin 325 mg daily for a client with transient ischemic attacks. The nurse explains that aspirin was prescribed to:
- A. Prevent headaches
- B. Boost coagulation
- C. Prevent cerebral anoxia
- D. Decrease platelet aggregation
Correct Answer: D
Rationale: Aspirin reduces platelet aggregation, preventing clot formation in transient ischemic attacks, reducing stroke risk. It does not prevent headaches, boost coagulation, or directly prevent anoxia.