Nokea
A client who received 6 units of packed red blood cells 3 days ago for a lower gastrointestinal (GI) bleed is now displaying signs of shortness of breath with occasional stridor and is reporting muscle cramping. Which serum laboratory value should the nurse immediately report to the healthcare provider?
- A. Potassium 4.7 mEq/L (4.70 mmol/L).
- B. Magnesium 2.1 mEq/L (0.86 mmol/L).
- C. Calcium 6.5 mg/dL (1.63 mmol/L).
- D. Sodium 135 mEq/L (135 mmol/L).
Correct Answer: C
Rationale: Calcium 6.5 mg/dL (1.63 mmol/L) is below the normal reference range and can cause muscle spasms, cramps, tingling, numbness, and stridor. This critical value should be immediately reported to the healthcare provider, as it can indicate a serious condition such as acute pancreatitis, sepsis, or massive blood transfusion.
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After initiating a steroid nebulizer treatment for a client with asthma in respiratory distress, which intervention is most important for the nurse to implement?
- A. Monitor pulse oximetry every 2 hours.
- B. Teach proper use of a rescue inhaler.
- C. Elevate the head of bed to 90 degrees.
- D. Determine exposure to asthmatic triggers.
Correct Answer: C
Rationale: Elevating the head of bed to 90 degrees improves breathing and oxygenation by reducing pressure on the diaphragm, increasing lung expansion, and facilitating mucus expectoration.
An older adult client with symptoms of osteoarthritis asks the nurse which form of exercise would be most beneficial. Which is the best response by the nurse?
- A. Jogging or running are excellent aerobic exercises.
- B. Tennis or racquetball will increase your muscle strength.
- C. Limit your exercise to just your daily activities.
- D. Swimming is an excellent exercise for you.
Correct Answer: D
Rationale: Swimming is a low-impact aerobic exercise that strengthens muscles, improves cardiovascular fitness, and enhances joint flexibility without putting stress on joints, making it ideal for osteoarthritis.
A client with type 1 diabetes mellitus, hypertension, and chronic kidney disease is to begin hemodialysis treatment. Which statement should the nurse include in client education?
- A. Prepare for an abdominal catheter.
- B. Continue routine medications.
- C. Expect the insulin dosage to be reduced.
- D. Include potassium-rich foods in the diet.
Correct Answer: C
Rationale: Insulin dosage may need to be reduced during hemodialysis because insulin is removed by the dialyzer and blood glucose levels may drop. This is the correct statement to include in client education.
A client with acquired immune deficiency syndrome (AIDS) and Pneumocystis jiroveci pneumonia has a CD4+ T cell count of 200 cells/mm³ (20%). The client asks the nurse why they have these recurring massive infections. Which pathophysiological mechanism should the nurse describe in response to this client's question?
- A. The humoral immune response lacks B cells that form antibodies and opportunistic infections result.
- B. Inadequate numbers of T lymphocytes are available to initiate cellular immunity and macrophages.
- C. Bone marrow suppression of white blood cells causes insufficient cells to phagocytize organisms.
- D. Exposure to multiple environmental infectious agents overburdens the immune system until it fails.
Correct Answer: B
Rationale: Inadequate numbers of CD4+ T cells impair cellular immunity, making the client susceptible to opportunistic infections like Pneumocystis jiroveci pneumonia due to HIV infection.
A client with a closed head injury demonstrates signs of syndrome of inappropriate antidiuretic hormone (SIADH). Which additional finding should the nurse expect to obtain?
- A. Weight gain of 2 pounds (0.91 kg) in one day.
- B. Fremitus over the chest wall.
- C. Serum sodium of 150 mEq/L (150 mmol/L).
- D. Urine specific gravity of 1.004.
Correct Answer: A
Rationale: Weight gain of 2 pounds (0.91 kg) in one day is a sign of fluid retention, which occurs in SIADH due to excessive secretion of antidiuretic hormone (ADH). ADH causes the kidneys to reabsorb water and reduce urine output, leading to hyponatremia and hypervolemia.