Nokea
A client is receiving continuous IV nitroprusside for severe hypertension. Which action should the nurse take?
- A. Keep calcium gluconate at the bedside.
- B. Monitor blood pressure every 2 hours.
- C. Limit IV exposure to light.
- D. Attach an inline filter to the IV tubing.
Correct Answer: C
Rationale: The correct action for the nurse to take is to limit IV exposure to light. Nitroprusside is light-sensitive, and exposure to light can lead to its degradation, potentially reducing its efficacy in treating severe hypertension. Keeping calcium gluconate at the bedside (Choice A) is not directly related to managing nitroprusside infusion. While monitoring blood pressure every 2 hours (Choice B) is important in managing hypertension, it is not the immediate action required to ensure medication efficacy. Attaching an inline filter to the IV tubing (Choice D) may help filter particles but does not address the critical concern of light sensitivity associated with nitroprusside administration.
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A client with chronic kidney disease is receiving dietary teaching from a nurse. Which of the following client statements indicates an understanding of the teaching?
- A. I will increase my intake of bananas.
- B. I will limit my intake of foods high in potassium.
- C. I will increase my intake of protein-rich foods.
- D. I will increase my intake of dairy products.
Correct Answer: B
Rationale: The correct answer is B. Limiting potassium-rich foods is crucial for clients with chronic kidney disease to prevent hyperkalemia, a common complication. Increasing intake of potassium-rich foods like bananas (choice A), protein-rich foods (choice C), or dairy products (choice D) can exacerbate hyperkalemia in these clients. Bananas, protein-rich foods, and dairy products are all high in potassium, which is detrimental for individuals with chronic kidney disease. Therefore, choices A, C, and D are incorrect.
A healthcare professional is preparing to administer an autologous blood product to a client. Which of the following actions should the healthcare professional take to identify the client?
- A. Match the client's identification band with the number on the blood unit
- B. Confirm the provider's prescription matches the number on the blood component
- C. Ask the client to state their blood type and confirm the date of their last blood donation
- D. Ensure that the client's identification band matches the number on the blood unit
Correct Answer: D
Rationale: Ensuring that the client's identification band matches the number on the blood unit is crucial for correct identification. This action helps prevent errors by confirming that the blood product is indeed intended for the specific client. Matching the client's blood type with type and cross-match specimens (Choice A) is important for compatibility but does not directly verify the client's identity. Confirming the provider's prescription (Choice B) is relevant but does not ensure the correct identification of the client. Asking the client to state their blood type and confirm the date of their last blood donation (Choice C) relies on the client's memory and verbal confirmation, which may not be accurate or reliable for identification purposes.
A nurse is caring for a client who is postoperative following abdominal surgery. Which of the following findings should the nurse report to the provider?
- A. Serous drainage at the incision site
- B. Temperature 38.2°C (100.8°F)
- C. Heart rate 92/min
- D. Blood pressure 130/80 mm Hg
Correct Answer: B
Rationale: The correct answer is B. An elevated temperature of 38.2°C (100.8°F) indicates a potential infection and should be reported to the provider. Elevated temperature postoperatively is often a sign of infection or inflammation, which can delay healing and increase the risk of complications. Choices A, C, and D are within normal ranges for a postoperative client and do not indicate an immediate need for reporting to the provider. Serous drainage at the incision site is expected in the initial postoperative period as part of the normal healing process, a heart rate of 92/min can be a normal response to surgery due to stress or pain, and a blood pressure of 130/80 mm Hg is also within normal limits for most clients.
A nurse is teaching a newly licensed nurse about ergonomic principles. Which of the following actions by the nurse indicates an understanding of the teaching?
- A. Stands with feet shoulder-width apart when lifting a client up in bed.
- B. Raises the client's knees before pulling the client up in bed.
- C. Uses a mechanical lift to move a client from bed to chair.
- D. Places a gait belt around the client's waist before assisting the client to stand.
Correct Answer: C
Rationale: Using a mechanical lift is an appropriate ergonomic technique as it reduces the risk of injury to both the nurse and the client by promoting safe client handling practices. Choice A is incorrect as standing with feet shoulder-width apart provides better balance and stability during lifting. Choice B is incorrect as raising the client's knees is not directly related to ergonomic principles. Choice D is incorrect as placing a gait belt around the client's waist is a safety measure but does not specifically demonstrate an understanding of ergonomic principles.
A client who has a new prescription for lithium is receiving teaching from a nurse. Which of the following statements by the client indicates an understanding of the teaching?
- A. ''I will avoid eating foods that contain tyramine.''
- B. ''I should increase my salt intake while taking this medication.''
- C. ''I should drink at least 2 liters of water each day while taking this medication.''
- D. ''I should avoid consuming caffeinated beverages while taking this medication.''
Correct Answer: C
Rationale: The correct answer is C. Drinking at least 2 liters of water daily is crucial for clients taking lithium to prevent dehydration and lithium toxicity. Lithium is a salt, so it's important for clients to maintain adequate hydration. Option A is incorrect because lithium does not interact with tyramine-containing foods. Option B is incorrect because increasing salt intake is not necessary and can actually exacerbate lithium toxicity. Option D is incorrect because avoiding caffeinated beverages is not a priority teaching point for clients taking lithium.