Nokea
A client with acute renal failure has an increase in the serum potassium level. The nurse should monitor the client for:
- A. Cardiac arrest.
- B. Pulmonary edema.
- C. Circulatory collapse.
- D. Hemorrhage.
Correct Answer: A
Rationale: Elevated potassium can cause cardiac arrhythmias, potentially leading to cardiac arrest, requiring close monitoring.
You may also like to solve these questions
A client with cancer has diarrhea and a nursing diagnosis of Impaired skin integrity related to the frequent diarrhea. Which of the following nursing interventions is appropriate for this diagnosis?
- A. Discourage sitz baths because they promote bacterial growth.
- B. Apply zinc oxide ointment to the rectal area after each bowel movement to protect the skin.
- C. Apply a skin-barrier dressing daily to the rectal area to form a protective barrier.
- D. Clean the rectal area with unscented soap and water after each bowel movement, rinse well, and pat dry.
Correct Answer: D
Rationale: Cleaning with unscented soap and water, rinsing, and patting dry after each bowel movement prevents skin breakdown and maintains integrity in clients with diarrhea.
The client who has been hospitalized with pancreatitis does not drink alcohol because of her religious convictions. She becomes upset when the physician persists in asking her about alcohol intake. The nurse should explain that the reason for these questions is that:
- A. There is a strong link between alcohol use and acute pancreatitis.
- B. Alcohol intake can interfere with the tests used to diagnose pancreatitis.
- C. Alcoholism is a major health problem, and all clients are questioned about alcohol intake.
- D. The physician must obtain the pertinent facts, regardless of religious beliefs.
Correct Answer: A
Rationale: Alcohol is a leading cause of acute pancreatitis, so the physician's questions are relevant to determine etiology (A). Options B, C, and D are inaccurate or dismissive of the client's concerns.
The nurse is taking care of a client with a spinal cord injury. The extent of the client’s injury is shown below. Which of the following findings is expected when assessing this client?
- A. Inability to move his arms
- B. Loss of sensation in his hands and fingers.
- C. Dysfunction of bowel and bladder.
- D. Difficulty breathing.
Correct Answer: C
Rationale: This client has a spinal cord injury of the sacral region of the spinal cord and will have bladder and bowel dysfunction, as well as loss of sensation and muscle control below the injury. The other options are true of a client who has quadriplegia.
A client who weighs 187 lb has an order to receive enoxaparin (Lovenox) 1 mg/kg. This drug is available in a concentration of 30 mg/0.3 mL. What dose would the nurse administer in milliliters?
- A. 0.85 mL
- B. 0.9 mL
- C. 0.95 mL
- D. 1.0 mL
Correct Answer: A
Rationale: Calculation: 187 lb ÷ 2.2 = 85 kg. Dose = 85 kg × 1 mg/kg = 85 mg. Concentration = 30 mg/0.3 mL = 100 mg/mL. Volume = 85 mg ÷ 100 mg/mL = 0.85 mL. Thus, the nurse administers 0.85 mL.
Which clinical manifestations should the nurse expect to assess in a client diagnosed with an overdose of a cholinergic agent?
- A. Dry mucous membranes.
- B. Urinary incontinence.
- C. Central nervous system (CNS) depression.
- D. Seizures.
- E. Skin rash.
Correct Answer: B,C,D
Rationale: Cholinergic overdose (e.g., organophosphates) causes urinary incontinence (B), CNS depression (C), and seizures (D) due to excessive acetylcholine. Dry mucous membranes and skin rash are not typical.