A client with chronic kidney disease is being assessed. Which laboratory value would be most concerning?
- A. Serum creatinine of 3.0 mg/dL
- B. Blood urea nitrogen (BUN) of 45 mg/dL
- C. Serum potassium of 6.5 mEq/L
- D. Hemoglobin of 10 g/dL
Correct Answer: C
Rationale: In a client with chronic kidney disease, an elevated serum potassium level (hyperkalemia) is the most concerning finding. Hyperkalemia can lead to life-threatening cardiac dysrhythmias due to its effect on the electrical conduction system of the heart. Monitoring and managing serum potassium levels are crucial in patients with chronic kidney disease to prevent serious complications. While elevated serum creatinine (Choice A) and Blood Urea Nitrogen (BUN) levels (Choice B) indicate impaired kidney function, hyperkalemia poses an immediate risk of cardiac complications. Hemoglobin levels (Choice D) are typically lower in chronic kidney disease due to decreased erythropoietin production, but they do not present an immediate life-threatening risk like hyperkalemia.
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A client with herpes zoster asks the nurse about using complementary and alternative therapies for pain control. The nurse should inform the client that this condition is a contraindication for which of the following therapies?
- A. Biofeedback
- B. Aloe
- C. Feverfew
- D. Acupuncture
Correct Answer: D
Rationale: Acupuncture is contraindicated for clients with herpes zoster due to the risk of introducing an open portal on the skin, which can increase the risk of infection. This therapy involves inserting needles into specific points on the body, potentially causing skin trauma and providing a route for the virus to spread. Biofeedback, aloe, and feverfew are not contraindicated for clients with herpes zoster and can be considered for pain management in this condition. Biofeedback involves using electronic devices to help individuals learn to control physiological processes, aloe is a plant known for its skin-soothing properties, and feverfew is an herb that has been used for pain relief.
A client is to receive 10 mEq of KCl diluted in 250 ml of normal saline over 4 hours. At what rate should the LPN/LVN set the client's intravenous infusion pump?
- A. 13 ml/hour
- B. 63 ml/hour
- C. 80 ml/hour
- D. 125 ml/hour
Correct Answer: B
Rationale: To calculate the correct rate of infusion, divide the total volume by the total time: 250 ml / 4 hours = 62.5 ml/hour, which is rounded up to 63 ml/hour. This rate ensures the proper administration of the KCl over the 4-hour period. Choice A (13 ml/hour) is incorrect as it does not match the calculated rate. Choices C (80 ml/hour) and D (125 ml/hour) are also incorrect as they do not correspond to the calculated rate needed for the specified time frame.
The LPN is caring for a client who has been placed in restraints. What is the most important action for the nurse to take?
- A. Ensure that the client's circulation is checked every hour.
- B. Document the reason for the restraints every 4 hours.
- C. Provide range-of-motion exercises every 2 hours.
- D. Release the restraints every 2 hours for repositioning.
Correct Answer: D
Rationale: The most crucial action for the nurse to take when caring for a client in restraints is to release the restraints every 2 hours for repositioning. This practice helps prevent complications such as pressure ulcers and impaired circulation by ensuring adequate blood flow and preventing skin breakdown. Checking the client's circulation every hour (Choice A) is important, but releasing the restraints for repositioning takes precedence to prevent serious complications. While documenting the reason for restraints (Choice B) is essential for legal and documentation purposes, it is not as critical as providing necessary care to the client's physical well-being. Providing range-of-motion exercises (Choice C) is beneficial for maintaining mobility but may not address the immediate risks associated with prolonged restraint use.
A nurse on a rehabilitation unit is preparing to transfer a client who is unable to walk from bed to a wheelchair. Which of the following techniques should the nurse use?
- A. Place the wheelchair at a 45-degree angle to the bed
- B. Position the wheelchair parallel to the bed
- C. Place the wheelchair in front of the bed
- D. Have the client stand and pivot into the wheelchair
Correct Answer: A
Rationale: Placing the wheelchair at a 45-degree angle to the bed is the correct technique for transferring a client who is unable to walk from bed to a wheelchair. This positioning facilitates a safer and easier transfer by providing more space for maneuvering and reducing the distance the client needs to be moved. Positioning the wheelchair parallel to the bed (Choice B) may make the transfer more challenging due to limited space and a longer distance to move the client. Placing the wheelchair in front of the bed (Choice C) may not provide an optimal angle for the transfer. Having the client stand and pivot into the wheelchair (Choice D) is not appropriate for a client who is unable to walk and could increase the risk of falls or injuries during the transfer.
A newly licensed nurse is preparing to administer medications to a client. The nurse notes that the provider has prescribed a medication that is unfamiliar. Which of the following actions should the nurse take?
- A. Consult the medication reference book available on the unit.
- B. Administer the medication as ordered.
- C. Ask a colleague for information about the medication.
- D. Contact the provider to clarify the medication.
Correct Answer: A
Rationale: When encountering an unfamiliar medication, the safest action for a nurse is to consult the medication reference book available on the unit. This resource provides accurate and detailed information about medications, including indications, dosages, side effects, and nursing considerations. Administering a medication without understanding it (choice B) can lead to medication errors and harm to the client. Asking a colleague for information (choice C) may not always provide accurate or up-to-date information. Contacting the provider (choice D) should be reserved for situations where immediate clarification is needed, but consulting the reference book is the initial step to gain knowledge and ensure safe medication administration.