Nokea
A client's lab results have just come in. The nurse reviews the electrolytes and contacts the health care provider regarding which result?
- A. chloride 167 mEq/L
- B. calcium 9.3 mg/dL
- C. phosphate 3.8 mg/dL
- D. sodium 141 mEq/L
Correct Answer: A
Rationale: Chloride 167 mEq/L is severely elevated (normal 98-106 mEq/L), requiring immediate attention. Other values are normal.
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The client presents to the emergency room with a 'bull's eye' rash. Which question would be most appropriate for the nurse to ask the client?
- A. Have you found any ticks on your body?'
- B. Have you had any nausea in the last 24 hours?'
- C. Have you been outside the country in the last 6 months?'
- D. Have you had any fever for the past few days?'
Correct Answer: A
Rationale: A bull's eye rash is characteristic of Lyme disease, often caused by tick bites, making this the most relevant question.
A client with cancer is to undergo a bone scan. The nurse should:
- A. Force fluids 24 hours before the procedure
- B. Ask the client to void immediately before the study
- C. Hold medication that affects the central nervous system for 12 hours pre- and post-test
- D. Cover the client's reproductive organs with an x-ray shield
Correct Answer: B
Rationale: Voiding immediately before a bone scan ensures the bladder is empty, reducing interference with pelvic imaging and improving the accuracy of the scan.
A patient is rushed to the emergency room after being found unconscious at home. His blood pressure is 70/35. The nurse anticipates an order for what medication?
- A. atropine sulfate (Atropine)
- B. amiodarone (Cordarone)
- C. magnesium sulfate
- D. adenosine (Adenoscan)
- E. None
- F. All the above
Correct Answer: E
Rationale: For severe hypotension (BP 70/35), vasopressors like norepinephrine or dopamine are typically ordered to restore perfusion, but none of the listed options are vasopressors. The question may be flawed.
A 38-year-old woman, mother of two, has a mastectomy for breast cancer. When she returns to the physician’s office a month later for a routine check-up, the nurse asks the client how she has been. Which of the following responses, if made by the client to the nurse, indicates that the client is experiencing a normal reaction to the surgery?
- A. I have been helping my family deal with their feelings about the surgery.
- B. I have been having difficulty coping with the surgery and cry frequently.
- C. I have been unable to leave the house or talk to my friends about the surgery.
- D. I am doing just great since the surgery and have gone back to work at my job.
Correct Answer: B
Rationale: normal reaction one month later
The nurse is caring for a client who is having surgery the next morning. The client says, 'I'm really scared about surgery. I've never been put to sleep before and I'm afraid I might not wake up.' Which response by the nurse is the most therapeutic?
- A. Why are you worried about such a minor procedure?
- B. We can call the doctor and cancel the surgery if you would prefer.
- C. It's normal to be afraid of something new like surgery. Tell me how you feel.
- D. Don't worry, you have a really good doctor and he will see to it that nothing goes wrong.
Correct Answer: C
Rationale: Acknowledging fear as normal and inviting the client to express feelings is therapeutic, fostering trust and emotional support.