Nokea
A client's serum sodium level is 113 mEq/L. The nurse would expect which findings upon assessment?
- A. headache, confusion, muscle weakness, fatigue
- B. hypertension, muscle cramps, respiratory depression
- C. cardiac arrhythmia, tetany, tachycardia
- D. confusion, nystagmus, tetany, hallucinations
Correct Answer: A
Rationale: Severe hyponatremia (113 mEq/L) causes neurological symptoms like headache, confusion, muscle weakness, and fatigue due to cerebral edema.
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Shortly after the client was admitted to the postpartum unit, the nurse notes heavy lochia rubra with large clots. The nurse should anticipate an order for:
- A. Methergine
- B. Stadol
- C. Magnesium sulfate
- D. Phenergan
Correct Answer: A
Rationale: Methergine promotes uterine contractions to control postpartum hemorrhage, indicated for heavy lochia with clots.
A client is hospitalized with signs of transplant rejection following a recent renal transplant. Assessment of the client would be expected to reveal:
- A. A weight loss of 2 pounds in 1 day
- B. A serum creatinine 1.25 mg/dL
- C. Urinary output of 50 mL/hr
- D. Rising blood pressure
Correct Answer: D
Rationale: Rising blood pressure is a sign of renal transplant rejection due to impaired kidney function and fluid retention.
All of the following are risk factors for sudden infant death syndrome (SIDS) EXCEPT
- A. low birth weight.
- B. placing the child on his back to sleep.
- C. young maternal age.
- D. maternal smoking during pregnancy.
Correct Answer: B
Rationale: Placing an infant on their back to sleep reduces SIDS risk. Low birth weight, young maternal age, and maternal smoking are known risk factors.
The nurse has performed nutritional teaching on a client with gout who is placed on a low-purine diet. Which selection by the client would indicate that teaching has been ineffective?
- A. Cabbage
- B. Apple
- C. Peach cobbler
- D. Spinach
Correct Answer: D
Rationale: Spinach is high in purines, which can exacerbate gout. Cabbage, apples, and peach cobbler (if low in purine ingredients) are suitable for a low-purine diet.
When drawing up a dosage of subcutaneous heparin, how much air should be drawn into the syringe after the correct dosage is obtained?
- A. 1 mL
- B. 0.6 mL
- C. 0.2 to 0.3 mL
- D. 0.01 mL
Correct Answer: C
Rationale: An air lock of 0.2-0.3 mL (C) is used in subcutaneous heparin injections to ensure the full dose is delivered and to prevent leakage.