A client is postoperative following a thyroidectomy. Which of the following findings should the nurse identify as an indication of hypocalcemia?
- A. Constipation
- B. Numbness and tingling of the fingers
- C. Increased thirst
- D. Frequent urination
Correct Answer: B
Rationale: Numbness and tingling of the fingers are classic signs of hypocalcemia, a condition that may result from inadvertent damage to the parathyroid glands during a thyroidectomy. These symptoms occur due to decreased levels of calcium in the bloodstream affecting nerve function. Choices A, C, and D are not typical manifestations of hypocalcemia. Constipation is more associated with hypercalcemia, increased thirst can be seen in diabetes or dehydration, and frequent urination is a symptom more commonly linked to conditions like diabetes or urinary tract issues.
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A client with COPD is receiving discharge teaching. Which statement indicates an understanding of the teaching?
- A. I will avoid breathing deeply while using my incentive spirometer.
- B. I will limit my fluid intake to 1 liter per day.
- C. I will exercise in an area that is humid.
- D. I will use pursed-lip breathing techniques.
Correct Answer: D
Rationale: The correct answer is D. Using pursed-lip breathing techniques is beneficial for clients with COPD as it helps control shortness of breath by keeping airways open longer. Option A is incorrect as deep breathing while using an incentive spirometer is essential to prevent complications such as atelectasis. Option B is incorrect because limiting fluid intake to 1 liter per day is not a standard recommendation for clients with COPD. Option C is incorrect as exercising in a humid area can exacerbate breathing difficulties for clients with COPD.
A client sustained a major burn over 20% of the body. What intervention should the nurse implement to meet the client's nutritional needs?
- A. Keep track of calorie intake for food and beverages.
- B. Provide a low-protein, high-carbohydrate diet.
- C. Schedule meals at 6-hour intervals.
- D. Provide a high-protein, high-calorie diet.
Correct Answer: D
Rationale: The correct answer is to provide a high-protein, high-calorie diet for a client with major burns. This type of diet is essential to support healing and recovery. High-protein intake is crucial as it helps in tissue repair and wound healing, while high-calorie intake is necessary to meet the increased metabolic demands of the body during the healing process. Keeping track of calorie intake (Choice A) is important but doesn't address the specific needs of a burn patient. Providing a low-protein, high-carbohydrate diet (Choice B) is not suitable for burn patients as they require adequate protein for wound healing. Scheduling meals at 6-hour intervals (Choice C) may be helpful for maintaining a consistent eating schedule, but it is not as crucial as providing the correct high-protein, high-calorie diet.
A nurse is reviewing the medical record of a client who has a new prescription for potassium chloride. Which of the following findings should the nurse report to the provider?
- A. Blood pressure 110/70 mm Hg
- B. Heart rate 88/min
- C. Serum potassium 3.2 mEq/L
- D. Sodium 136 mEq/L
Correct Answer: C
Rationale: The correct answer is C. A serum potassium level of 3.2 mEq/L is below the normal range, indicating hypokalemia. Before administering potassium chloride, which is used to treat low potassium levels, the nurse should report this finding to the provider for further evaluation and potential adjustment of the treatment plan. Choices A, B, and D are within normal ranges and do not directly relate to the need for potassium chloride administration.
A nurse is preparing to administer potassium chloride IV to a client who has hypokalemia. Which of the following actions should the nurse take?
- A. Give the medication as a bolus over 10 minutes.
- B. Dilute the medication before administration.
- C. Infuse the medication at a rate of 10 mEq/hr.
- D. Administer the medication undiluted.
Correct Answer: C
Rationale: The correct action the nurse should take when administering potassium chloride IV to a client with hypokalemia is to infuse the medication at a rate of 10 mEq/hr. This slow infusion rate is crucial to prevent the development of hyperkalemia, a potentially dangerous condition. Option A is incorrect because giving the medication as a bolus over 10 minutes can lead to adverse effects. Option B is incorrect as potassium chloride does not necessarily need to be diluted before administration in this scenario. Option D is incorrect as administering the medication undiluted can also increase the risk of hyperkalemia.
A nurse is reviewing the medical record of a client who is receiving morphine for pain management. Which of the following findings should the nurse report to the provider?
- A. Heart rate of 88/min
- B. Pain rating of 4 on a scale of 0 to 10
- C. Respiratory rate of 10/min
- D. Temperature of 37.2°C (99°F)
Correct Answer: C
Rationale: The correct answer is C. A respiratory rate of 10/min indicates respiratory depression, a serious adverse effect of morphine that should be reported immediately. Options A, B, and D are within acceptable ranges and not indicative of life-threatening complications when administering morphine.