Nokea
A client with a history of chronic kidney disease is admitted with hyperkalemia. The nurse should prioritize which of the following interventions?
- A. Administer insulin and glucose.
- B. Restrict potassium-rich foods.
- C. Administer a loop diuretic.
- D. Monitor for dysrhythmias.
Correct Answer: D
Rationale: Monitoring for dysrhythmias is the priority, as hyperkalemia can cause life-threatening cardiac arrhythmias.
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Which of the following impacts on the client's preferences in terms of hygiene routines and practices?
- A. Culture
- B. Locus of control
- C. Bodily surface area
- D. Diaphoresis
Correct Answer: A
Rationale: Culture significantly influences hygiene preferences, as beliefs and practices vary widely across cultural groups.
A client has started taking amiodarone (Cordarone). The nurse should inform the client that periodic laboratory tests will be done to monitor the client's:
- A. Hemoglobin.
- B. Liver enzymes.
- C. Creatine kinase (CK) concentration.
- D. Renal function.
Correct Answer: B
Rationale: Amiodarone can cause hepatotoxicity, so periodic monitoring of liver enzymes is necessary to detect potential liver damage.
A client with a diagnosis of hyperthyroidism is prescribed propylthiouracil (PTU). The nurse should monitor the client for which of the following side effects?
- A. Weight gain.
- B. Agranulocytosis.
- C. Hypertension.
- D. Hyperglycemia.
Correct Answer: B
Rationale: Propylthiouracil can cause agranulocytosis, requiring monitoring of white blood cell counts.
You have loosely applied a bed sheet around your client's waist to prevent a fall from the chair. What have you done?
- A. Ensured the client's safety which is a high patient care priority
- B. Violated Respondeat Superior
- C. Violated the client's right to dignity
- D. Committed a crime
Correct Answer: D
Rationale: Applying a bed sheet around the client's waist without a proper restraint order constitutes an illegal restraint, which is a crime , as it restricts freedom without proper authorization or consent.
A nurse is preparing to administer 500 mL of an I.V. solution to a child over 12 hours via tubing that delivers microdrips at 60 gtt/mL. At what rate should the nurse infuse the solution?
- A. 42 gtt/minute.
- B. 83 gtt/minute.
- C. 60 gtt/minute.
- D. 21 gtt/minute.
Correct Answer: A
Rationale: Calculate: 500 mL over 12 hours = 41.67 mL/hour. For microdrip (60 gtt/mL), 41.67 mL/hour ×60 gtt/mL = 2500 gtt/hour ÷ 60 minutes = 41.67 gtt/minute, rounded to 42 gtt/minute.