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A client receives discharge teaching for a new prescription of lithium. Which instruction should be included?
- A. Take the medication with food.
- B. Increase your intake of sodium.
- C. Monitor for signs of hypercalcemia.
- D. Avoid consuming dairy products.
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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The LPN/LVN is assisting in caring for a client in the telemetry unit who is receiving an intravenous infusion of 1000 mL of 5% dextrose with 40 mEq of potassium chloride. Which occurrence observed on the cardiac monitor indicates the presence of hyperkalemia?
- A. Tall, peaked T waves
- B. ST segment depressions
- C. Shortened P-R intervals
- D. Shortening of the QRS complex
Correct Answer: A
Rationale: In hyperkalemia, tall, peaked T waves are a distinct ECG finding. These T waves can be seen as a result of increased serum potassium levels, affecting the repolarization phase of the cardiac action potential. It is crucial for healthcare providers to recognize this ECG change promptly as hyperkalemia can lead to serious cardiac arrhythmias and complications.
The healthcare provider notes this rhythm on the client's cardiac monitor. The healthcare provider next reports that the client is experiencing which heart rhythm?
- A. Normal sinus
- B. Atrial fibrillation
- C. Sinus bradycardia
- D. Ventricular fibrillation
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
While preparing a client for a cardiac catheterization, the client expresses a preference to speak with their doctor rather than the nurse. Which response by the nurse should be therapeutic?
- A. Your doctor expects me to prepare you for this procedure.
- B. That's fine, if that's what you want. I'll call your health care provider.
- C. So you're saying that you want to talk to your health care provider?
- D. I'm concerned with the way you've dismissed me. I know what I am doing.
Correct Answer: C
Rationale: The therapeutic response by the nurse in this situation involves reflecting the client's feelings back to them, which demonstrates active listening and empathy. By restating the client's preference to talk to their doctor, the nurse acknowledges and validates the client's feelings, thereby fostering a positive therapeutic relationship and promoting open communication.
The client will wear a Holter monitor for continuous cardiac monitoring over the next 24 hours. What action should the nurse take to assist the client?
- A. Shave the front of the client's chest
- B. Give the client a device holder to wear around the waist
- C. Teach the client to rest as much as possible during the next 24 hours
- D. Tell the client to cover the monitor in plastic wrap before taking a bath
Correct Answer: B
Rationale: Providing the client with a device holder to wear around the waist allows them to comfortably carry the Holter monitor while engaging in normal activities throughout the 24-hour monitoring period. This approach supports the client's mobility and ensures the monitor is securely in place for accurate readings.
A client with coronary artery disease is prescribed a low-cholesterol diet. The nurse should reinforce which dietary selection made by the client?
- A. Eggs and bacon
- B. Oatmeal with fresh fruit
- C. Cream of chicken soup
- D. Grilled cheese sandwich
Correct Answer: B
Rationale: Oatmeal with fresh fruit is a suitable choice for a client with coronary artery disease prescribed a low-cholesterol diet. This option is high in fiber and nutrients, making it a heart-healthy selection. In contrast, choices A, C, and D are higher in cholesterol and saturated fats, which can be detrimental for individuals with coronary artery disease.