Nokea
A client with acute renal failure has a potassium level of 6.5 mEq/L. The nurse should prepare for:
- A. IV insulin and glucose.
- B. Oral potassium supplements.
- C. Fluid restriction.
- D. Diuretic administration.
Correct Answer: A
Rationale: Insulin and glucose shift potassium into cells, treating hyperkalemia.
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Which goal is the most realistic and appropriate for a client diagnosed with Parkinson's disease?
- A. To cure the disease.
- B. To stop progression of the disease.
- C. To begin preparations for terminal care.
- D. To maintain optimal body function.
Correct Answer: D
Rationale: Maintaining optimal body function is realistic, focusing on symptom management and quality of life. Parkinson's is incurable, progression cannot be stopped, and terminal care is premature for most clients.
A female receiving radiation therapy for lung cancer complains to the nurse that she is having difficulty sleeping. Which of the following nursing actions is most appropriate?
- A. Suggest the client stop watching television before bed.
- B. Assess the client's usual sleep patterns, amount of sleep, and bedtime rituals.
- C. Tell the client sleeplessness is expected with radiation therapy.
- D. Suggest that the client stop drinking coffee until the therapy is completed.
Correct Answer: B
Rationale: Assessing sleep patterns, amount of sleep, and bedtime rituals provides a comprehensive understanding of the client's insomnia, enabling tailored interventions.
The nurse devises a teaching plan for the client with aplastic anemia. Which of the following is the most important concept to teach for health promotion and maintenance?
- A. Eat animal protein and dark green, leafy vegetables and eggs.
- B. Avoid exposure to others with acute infections.
- C. Practice yoga and meditation to decrease stress and anxiety.
- D. Get 8 hours of sleep at night and take naps during the day.
Correct Answer: B
Rationale: Aplastic anemia is characterized by bone marrow failure, leading to low blood cell counts and increased risk of infection due to neutropenia. The most important health promotion strategy is to avoid exposure to infections, as infections can be life-threatening in these clients. While nutrition, stress management, and sleep are important, infection prevention is the priority.
Which of the following techniques for administering the Mantoux test is correct?
- A. Hold the needle and syringe almost parallel to the client's skin.
- B. Pinch the skin when inserting the needle.
- C. Aspirate before injecting the medication.
- D. Massage the site after injecting the medication.
Correct Answer: A
Rationale: The Mantoux test requires intradermal injection, with the needle held almost parallel to the skin to form a wheal. Pinching, aspirating, or massaging disrupts the test's accuracy.
A client at risk for lung cancer asks why he is scheduled for a computed tomography (CT) scan as part of his initial workup. The nurse's best response is which of the following?
- A. CT is far superior to magnetic resonance imaging for evaluating lymph node metastasis.
- B. CT is noninvasive and readily available.
- C. CT is useful for distinguishing small differences in tissue density and detecting nodal involvement.
- D. CT can distinguish a malignant from a nonmalignant adenopathy.
Correct Answer: C
Rationale: CT scans are valuable in lung cancer workups because they can detect small differences in tissue density and identify nodal involvement, aiding in staging and diagnosis.