Nokea
A client on hemodialysis reports muscle cramps. The nurse should:
- A. Increase dialysate flow.
- B. Check electrolyte levels.
- C. Administer a diuretic.
- D. Encourage ambulation.
Correct Answer: B
Rationale: Muscle cramps may indicate electrolyte imbalances, requiring lab assessment.
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A client is admitted to the emergency department with a headache, weakness, and slight confusion. The physician diagnoses carbon monoxide poisoning. What should the nurse do first?
- A. Initiate gastric lavage.
- B. Maintain body temperature.
- C. Administer 100% oxygen by mask.
- D. Obtain a psychiatric referral.
Correct Answer: C
Rationale: Administering 100% oxygen displaces carbon monoxide from hemoglobin, the priority in poisoning. Gastric lavage, temperature maintenance, and psychiatric referrals are secondary.
A client is admitted to the surgical floor after having bowel surgery. The nurse observes that the client's urine output has decreased from 50 to 20 mL/hour. Which of the following is the most likely cause?
- A. Bowel obstruction.
- B. Adverse effect of opioid analgesics.
- C. Hemorrhage.
- D. Hypertension.
Correct Answer: B
Rationale: Opioid analgesics, commonly used post-surgery, can cause urinary retention by relaxing the bladder, reducing urine output. This is the most likely cause in this scenario.
A client undergoes a laparoscopic cholecystectomy. Which of the following dietary instructions should the nurse give the client immediately after surgery?
- A. You cannot eat or drink anything for 24 hours.
- B. You may resume your normal diet the day after your surgery.
- C. Drink liquids today and eat lightly for a few days.
- D. You can progress from a liquid to a bland diet as tolerated.
Correct Answer: C
Rationale: Post-laparoscopic cholecystectomy, patients typically start with clear liquids and progress to light meals to avoid gastrointestinal stress. Option C is most appropriate. Option A is too restrictive, B is premature, and D is less specific.
Which of the following should the nurse include in the discharge plan for a client with multiple sclerosis who has an impaired peripheral sensation?
- A. Carefully test the temperature of bath water.
- B. Avoid kitchen activities because of the risk of injury.
- C. Avoid hot water bottles and heating pads.
- D. Inspect the skin daily for injury or pressure points.
- E. Wear warm clothing when outside in cold temperatures.
Correct Answer: A,C,D,E
Rationale: Testing bath water temperature (A), avoiding hot water bottles/heating pads (C), daily skin inspection (D), and wearing warm clothing (E) prevent injury due to impaired sensation. Avoiding kitchen activities entirely is overly restrictive.
A small airplane crashes in a neighborhood of 10 houses. One of the victims appears to have a cervical spine injury. What should first-aid for this victim should be selected that apply.
- A. Establish an airway with the jaw-thrust maneuver.
- B. Immobilize the spine.
- C. Logroll the victim to a side-lying position.
- D. Elevate the feet 6" (15.2 cm).
- E. Place a cervical collar around the neck.
Correct Answer: A,B,E
Rationale: For a suspected cervical spine injury, the airway should be opened with the jaw-thrust maneuver, the spine immobilized, and a cervical collar applied to prevent further injury. Logrolling or elevating feet could exacerbate the injury.