Nokea
A client with acute renal injury (AKI) weighs 110.3 pounds (50 kg) and has a potassium level of 6.7 mEq/L (6.7 mmol/L) is admitted to the hospital. Which prescribed medication should the nurse administer first?
- A. Sodium polystyrene sulfonate 15 grams by mouth.
- B. Sevelamer one tablet by mouth.
- C. Calcium acetate one tablet by mouth.
- D. Epoetin alfa, recombinant 2,500 units subcutaneously.
Correct Answer: A
Rationale: Sodium polystyrene sulfonate is a medication that binds to excess potassium in the gastrointestinal tract and removes it from the body through feces. It is used to treat hyperkalemia, which is a high level of potassium in the blood. Hyperkalemia can cause cardiac arrhythmias and muscle weakness, and it is a common complication of AKI. Therefore, this medication should be administered first to lower the potassium level and prevent life-threatening complications.
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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.
In assessing a client with ulcers on the lower extremity, which findings indicate that the ulcers are likely to be of venous, rather than arterial, origin?
- A. Irregular ulcer shapes and severe edema.
- B. Hairless lower extremities and cool feet.
- C. Black ulcers and dependent rubor.
- D. Absent pedal pulses and shiny skin.
Correct Answer: A
Rationale: Irregular ulcer shapes and severe edema are characteristic of venous ulcers, caused by impaired venous return and increased capillary pressure.
History and physical
Flow sheet
Nurses’ Notes
Imaging studies 1935
A 70-year-old female presents to the emergency department through triage with a noticeable facial droop and garbled speech. After having a few drinks at a local seafood restaurant, the patient’s husband noticed his wife’s speech became difficult to understand
Specify which findings indicate early interventions for an ischemic stroke were effective? Focused assessment area: Neurological, Muscoskeletal, Psychosocial
- A. Neurological: Drinks with repetitive cough, Speaks in short sentences, Decorticate posturing; Muscoskeletal: Flaccidity of left arm, Ambulates with a walker, Passive range of motion on left leg; Psychosocial: Fits of laughter, Tearful sharing of stories, Angry outburst
- B. Neurological: Speaks in short sentences; Muscoskeletal: Ambulates with a walker; Psychosocial: Tearful sharing of stories
Correct Answer: B,B,B
Rationale: Neurological: Speaking in short sentences indicates improved speech from garbled to intelligible. Muscoskeletal: Ambulating with a walker shows regained mobility. Psychosocial: Tearful sharing of stories reflects normal emotional expression and preserved memory, indicating effective early interventions.
A client with gouty arthritis reports tenderness and swelling of the right ankle and great toe. The nurse observes the area of inflammation extends above the ankle area. The client receives prescriptions for colchicine and indomethacin. Which instruction should the nurse include in the discharge teaching?
- A. Return for periodic liver function studies.
- B. Massage joints to relax muscles and decrease pain.
- C. Limit use of mobility equipment to avoid muscle atrophy.
- D. Substitute natural fruit juices for carbonated drinks.
Correct Answer: A
Rationale: Returning for periodic liver function studies is important because colchicine and indomethacin can cause liver toxicity, which should be monitored through regular blood tests.
Two weeks after returning home from traveling, a client presents to the clinic with conjunctivitis and describes a recent loss in the ability to taste and smell. The nurse obtains a nasal swab to test for COVID-19. Which action is most important for the nurse to take?
- A. Teach the client to wear a mask, hand wash, and social distance to prevent spreading the virus.
- B. Isolate the client from other clients, family, and healthcare workers not wearing proper PPE.
- C. Report the COVID-19 result to the local health department according to CDC guidelines.
- D. Explain to the client to inform others that they may have been potentially exposed in the last 14 days.
Correct Answer: B
Rationale: Isolating the client from others not wearing proper PPE is the most important action to prevent transmission of COVID-19, given the client's symptoms suggestive of the virus.