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A client with chronic kidney disease has a potassium level of 6.2 mEq/L. Which intervention should the nurse implement?
- A. Encourage the client to eat foods rich in potassium
- B. Administer a potassium-sparing diuretic
- C. Administer a potassium-binding medication
- D. Hold all medications containing potassium
Correct Answer: C
Rationale: A potassium level of 6.2 mEq/L indicates hyperkalemia, which is dangerous and requires immediate treatment. Administering a potassium-binding medication will help lower potassium levels and prevent life-threatening complications.
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The nurse is responsible for several elderly clients, including a client on bed rest with a skin tear and hematoma from a fall 2 days ago. What is the best care assignment for this client?
- A. Assign an RN to supervise a nursing assistant for skin care
- B. Assign a nursing assistant to help the client with self-care activities
- C. Delegate complete care to an unlicensed assistive personnel
- D. Supervise a nursing assistant for skin care
Correct Answer: D
Rationale: In this scenario, the best care assignment for the client with a skin tear and hematoma is to supervise a nursing assistant for skin care. This ensures proper wound care while utilizing the skills of the nursing assistant effectively. Assigning an RN to supervise the nursing assistant is appropriate as it provides the necessary expertise for wound care supervision. Delegating complete care to an unlicensed assistive personnel may not be suitable for a client with specific wound care needs. Helping the client with self-care activities may not directly address the urgent need for proper wound care in this situation.
The nurse is preparing a client who had a BKA amputation for discharge to home. Which recommendations should the nurse provide this client?
- A. All of the above
- B. Inspect the skin for redness
- C. Use a residual limb shrinker
- D. Wash the stump with soap and water
Correct Answer: A
Rationale: Proper care of the residual limb is essential in preventing complications like infection or poor healing. By choosing 'All of the above,' the nurse ensures that the client receives comprehensive care. Inspecting the skin for redness is crucial as it can help in early detection of infections. Using a residual limb shrinker helps reduce swelling and maintain proper shaping of the limb. Washing the stump with soap and water on a daily basis is important for hygiene and preventing infections. Therefore, all the recommendations (choices A, B, and C) are essential for the client's care, making choice A the correct answer. Choice D is incorrect as it does not encompass all the necessary recommendations for the client's care.
A client presents with severe dehydration due to prolonged vomiting. What is the nurse's priority intervention?
- A. Encourage the client to drink clear fluids.
- B. Assess the client's skin turgor and mucous membranes.
- C. Monitor the client's vital signs frequently.
- D. Administer an antiemetic as prescribed.
Correct Answer: B
Rationale: The correct answer is to assess the client's skin turgor and mucous membranes. When a client presents with severe dehydration, assessing skin turgor (elasticity of the skin) and mucous membranes (such as checking for dryness in the mouth) is crucial in determining the extent of dehydration. Encouraging the client to drink clear fluids (Choice A) may be important but assessing dehydration severity takes precedence. Monitoring vital signs (Choice C) is essential but assessing dehydration status comes first. Administering an antiemetic (Choice D) addresses vomiting but does not directly assess dehydration.
The nurse is providing care for a client receiving total parenteral nutrition (TPN). Which action should the nurse include in the client's plan of care?
- A. Increase the TPN infusion rate if the client is hungry
- B. Administer TPN via a peripheral IV line
- C. Monitor blood glucose levels regularly
- D. Ensure the TPN solution is refrigerated at all times
Correct Answer: C
Rationale: The correct action the nurse should include in the client's plan of care is to monitor blood glucose levels regularly. Clients receiving TPN are at risk for hyperglycemia due to the high glucose content of the solution. Regular monitoring of blood glucose levels is essential to ensure appropriate management of blood sugar. Choice A is incorrect because increasing the TPN infusion rate based on hunger is not a valid parameter for adjusting TPN. Choice B is incorrect because TPN should be administered through a central line, not a peripheral IV line, to prevent complications. Choice D is incorrect because TPN solutions should be stored at room temperature, not refrigerated.
A client with hypertension is prescribed a beta-blocker. What teaching should the nurse provide about this medication?
- A. Instruct the client to avoid high-potassium foods.
- B. Monitor the client's heart rate and report any bradycardia.
- C. Advise the client to rise slowly from a sitting or lying position.
- D. Instruct the client to avoid sudden position changes.
Correct Answer: C
Rationale: The correct answer is to advise the client to rise slowly from a sitting or lying position. Beta-blockers can cause bradycardia and hypotension, so clients should be advised to rise slowly to prevent dizziness and falls. Monitoring the client's heart rate and blood pressure regularly is essential. Instructing the client to avoid high-potassium foods (Choice A) is not directly related to beta-blockers. While monitoring the client's heart rate (Choice B) is important, advising the client to rise slowly (Choice C) is more directly related to potential side effects of beta-blockers. Instructing the client to avoid sudden position changes (Choice D) is not as specific or essential as advising them to rise slowly to prevent adverse effects.