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A client with hyperkalemia may exhibit peaked T waves on an electrocardiogram. This manifestation is an early sign of high potassium levels, but the diagnosis should not be based on this aspect alone. Untreated, hyperkalemia can lead to progressively worsening cardiac instability.
- A. A lumbar puncture takes a sample of cerebrospinal fluid from the back, which will be analyzed by the lab.
- B. The physician will insert a needle at the level of L4-L5 in the spinal cord.
- C. The client should lie flat on their back for a specific period following the procedure.
- D. The risks of the procedure include headache, back pain, and infection.
Correct Answer: B
Rationale: A lumbar puncture is performed to obtain cerebrospinal fluid for analysis to investigate various conditions affecting the client. During the procedure, the client is typically positioned on their side or sitting leaning over a table with their back rounded. The physician inserts a needle into the back around the L4-L5 vertebrae to collect the sample. Option A is incorrect because a lumbar puncture does not draw blood but instead collects cerebrospinal fluid. Option C is incorrect as the client should not necessarily lie flat for 24 hours post-procedure. Option D is incorrect as the common risks of a lumbar puncture include headache, back pain, and potential infection, not nausea, rash, or hypotension.
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The nurse has given instructions to the client diagnosed with chronic kidney disease about reducing pruritus from uremia. The nurse determines that the client needs further teaching if the client states the intention to use which item for skin care?
- A. Mild soap
- B. Oil in the bath water
- C. Lanolin-based lotion
- D. Alcohol cleansing pads
Correct Answer: D
Rationale: Alcohol cleansing pads increase skin dryness and pruritus in chronic kidney disease clients with uremia. Mild soap, bath oils, and lanolin-based lotions help reduce dryness and irritation without exacerbating symptoms.
The nurse has conducted a class for pregnant clients diagnosed with diabetes mellitus about the signs/symptoms of potential complications. The nurse determines that the teaching was effective if a client makes which statement?
- A. I should not have ultrasounds done because I am diabetic.
- B. I'm glad I don't have to worry about developing hypoglycemia while I am pregnant.
- C. I need to watch my weight for any sudden gains because I could develop what they call gestational hypertension.
- D. My insulin needs should decrease during the last 2 months because I will be using some of the baby's insulin supply.
Correct Answer: C
Rationale: A diabetic pregnant client has a higher incidence of developing gestational hypertension than the nondiabetic pregnant client does. Ultrasounds are done frequently during a diabetic pregnancy to check for congenital anomalies and to determine appropriate growth patterns. Hypoglycemia is a problem during pregnancy in the client diagnosed with diabetes mellitus and needs to be assessed throughout the pregnancy. Insulin needs will increase during the last trimester because of increased hormone levels that destroy circulating insulin.
A client diagnosed with anxiety disorder is prescribed buspirone orally. When the client reports that it is difficult to swallow the tablets, the nurse provides which instruction to promote compliance?
- A. Crush the tablets before taking them.
- B. Mix the tablet uncrushed in applesauce.
- C. Purchase the liquid preparation with the next refill.
- D. Call the primary health care provider for a change in medication.
Correct Answer: A
Rationale: Buspirone tablets may be crushed and administered without regard to meals, making this the most effective instruction to promote compliance for a client who finds swallowing difficult. Mixing the tablet uncrushed in applesauce does not address the swallowing issue. Buspirone is not available in liquid form, and calling the primary health care provider for a medication change is premature before trying this intervention.
Which of the following situations might warrant a laboratory magnesium level?
- A. Hyperthyroidism
- B. Arthritis
- C. Ulcerative colitis
- D. Depression
Correct Answer: C
Rationale: Ulcerative colitis can lead to symptoms such as abdominal pain, fever, diarrhea, and weight loss. This condition may impact the absorption of certain nutrients, including magnesium. Therefore, patients with chronic gastrointestinal conditions like ulcerative colitis should be screened for electrolyte imbalances related to impaired digestion. Hyperthyroidism, arthritis, and depression do not typically directly affect magnesium levels in the same way as gastrointestinal conditions like ulcerative colitis.
A client is preparing to give a stool sample for occult blood. All of the following information is part of teaching for this client EXCEPT:
- A. Avoid eating red meat for 3 days before the test
- B. Collect the stool sample from the toilet after having a bowel movement
- C. The stool does not need to be kept in a container with preservative
- D. A small part of the stool from two areas will be tested using a smear
Correct Answer: B
Rationale: When preparing to give a stool sample for occult blood testing, clients need specific instructions to ensure accurate results. It is crucial to educate clients to avoid eating red meat for at least 3 days before the test, as the blood in the meat can interfere with the test results. Clients should be informed that the stool does not need to be kept in a container with preservative as it is not required for this type of testing. Additionally, clients should be aware that a small part of the stool from two areas will be tested using a smear. However, collecting the stool sample from the toilet after having a bowel movement is not recommended as it may introduce contaminants and affect the accuracy of the test. Therefore, this information is not part of the correct teaching for the client preparing to give a stool sample for occult blood.