Nokea
A client with a history of heart failure is prescribed furosemide (Lasix). The nurse should monitor the client for which of the following electrolyte imbalances?
- A. Hyperkalemia.
- B. Hypokalemia.
- C. Hypernatremia.
- D. Hypocalcemia.
Correct Answer: B
Rationale: Furosemide, a loop diuretic, can cause hypokalemia by increasing potassium excretion in the urine.
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The nurse caring for a client after shoulder arthroplasty for rheumatoid arthritis monitors the client for brachial plexus compromise. To assess the status of the median nerve, which action would the nurse perform?
- A. Have the client spread all of the fingers wide and resist pressure.
- B. Monitor for flexion of the biceps by having the client raise the forearm.
- C. Have the client move the thumb toward the palm and back to the neutral position.
- D. While grasping the nurse's hand, note the strength of the client's first and second fingers.
Correct Answer: D
Rationale: To assess the median nerve status, the client should be instructed to grasp the nurse's hand. The nurse should note the strength of the client's first and second fingers. A weak grip may indicate compromise of the median nerve. Asking the client to spread all fingers wide and resist pressure assesses the ulnar nerve status. Monitoring for flexion of the biceps by raising the forearm assesses the cutaneous nerve status. Asking the client to move the thumb toward the palm and back to neutral position assesses the radial nerve status.
A nurse is relieving the triage nurse in the labor and delivery unit who is going to lunch. The report indicates that there are three clients having their vital signs assessed and a fourth client is on her way to the unit from the emergency department. In which order of priority should the nurse manage these clients?
- A. The client with clear vesicles and brown vaginal discharge at 16 weeks' gestation.
- B. The client with right lower quadrant pain at 10 weeks' gestation.
- C. The client who is at term and has had no fetal movement for 2 days.
- D. The client from the emergency department at term and screaming loudly because of labor contractions.
Correct Answer: C,D,A,B
Rationale: The client with no fetal movement at term is the highest priority due to the risk of fetal distress. The client in active labor requires immediate attention. Vesicles and discharge suggest possible infection, and right lower quadrant pain may indicate ectopic pregnancy, both serious but less urgent.
The 2nd priority needs according to the MAAUAR method of priority setting include which of the following?
- A. Assessment
- B. Movement
- C. Understanding level
- D. Risks
Correct Answer: D
Rationale: The MAAUAR method prioritizes: Mental status, Acute pain, Acute eliminated needs, Urgent needs, Abnormal vital signs, Risks. The second priority is Acute pain, but among the options, Risks aligns as a high-priority need following initial physiological concerns.
The nurse is providing bottle-feeding instructions to the mother of a newborn infant. The nurse provides instructions regarding the amount of formula to be given, knowing that what is the approximate stomach capacity for a newborn?
- A. 5 to 10 mL
- B. 10 to 20 mL
- C. 30 to 90 mL
- D. 75 to 100 mL
Correct Answer: B
Rationale: The stomach capacity of a newborn is approximately 10 to 20 mL. It is 30 to 90 mL for a 1-week-old infant and 75 to 100 mL for a 2- to 3-week-old infant.
The nurse obtains a finger-stick glucose of 400 mg/dL (22.85 mmol/L) for a client who receives total parenteral nutrition (TPN). Which follow-up intervention should the nurse implement?
- A. Discontinue the current TPN infusion.
- B. Decrease the infusion rate of the TPN.
- C. Replace TPN with 5% dextrose solution.
- D. Confer with provider for glucose control.
Correct Answer: D
Rationale: A glucose level of 400 mg/dL indicates significant hyperglycemia, which is a potential complication of TPN due to its high dextrose content. The nurse should confer with the primary health care provider to obtain orders for glucose control, such as insulin administration, to manage the hyperglycemia safely. Discontinuing or altering the TPN infusion without provider orders is inappropriate, as TPN is a critical nutrition source, and abrupt changes could cause metabolic imbalances. Replacing TPN with 5% dextrose would not address the hyperglycemia and could exacerbate it.