Nokea
A female client reports that she drank a liter of a solution to cleanse her intestines but vomited immediately after. How many ml of fluid intake should the nurse document?
- A. 1000 ml
- B. 800 ml
- C. 760 ml
- D. 500 ml
Correct Answer: C
Rationale: The correct answer is 760 ml. One liter equals 1000 ml. As the client vomited immediately after drinking, she would have expelled approximately 240 ml (1 cup). Subtracting this from the initial intake of 1000 ml gives us 760 ml as the remaining fluid intake that should be documented. Choices A, B, and D are incorrect because they do not reflect the correct calculation of subtracting the amount vomited from the initial intake.
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A client with a history of chronic heart failure is admitted with shortness of breath and crackles in the lungs. Which intervention should the nurse implement first?
- A. Administer oxygen therapy as prescribed.
- B. Administer a loop diuretic as prescribed.
- C. Administer intravenous morphine as prescribed.
- D. Obtain an arterial blood gas (ABG) sample.
Correct Answer: A
Rationale: Administering oxygen therapy is the priority intervention for a client with chronic heart failure presenting with shortness of breath and crackles in the lungs. Oxygen therapy helps improve oxygenation, which is crucial in managing respiratory distress. Loop diuretics (Choice B) may be indicated to manage fluid overload in heart failure but are not the immediate priority in this case. Administering morphine (Choice C) is not the first-line intervention for shortness of breath in heart failure and should be considered after addressing oxygenation and underlying causes. Obtaining an arterial blood gas sample (Choice D) can provide valuable information but is not the initial action needed to address the client's acute respiratory distress.
A client with diabetes mellitus is admitted with a blood glucose level of 640 mg/dl and is unresponsive. Which intervention should the nurse implement first?
- A. Administer 50% dextrose IV push
- B. Administer IV fluids as prescribed
- C. Check the client's blood glucose level
- D. Prepare the client for immediate dialysis
Correct Answer: B
Rationale: Administering IV fluids as prescribed is the priority intervention in a client with a blood glucose level of 640 mg/dl and unresponsiveness. Severe hyperglycemia can lead to dehydration and electrolyte imbalances, and administering IV fluids can help manage hyperglycemia and prevent further complications. Administering dextrose IV push (Choice A) can exacerbate hyperglycemia in this scenario. Checking the client's blood glucose level (Choice C) is important but not the immediate priority when the client is unresponsive. Immediate dialysis (Choice D) is not indicated as the first intervention for hyperglycemia.
A client with chronic kidney disease (CKD) is admitted with hyperkalemia. Which laboratory value requires immediate intervention?
- A. Serum potassium of 6.5 mEq/L
- B. Serum sodium of 135 mEq/L
- C. Serum creatinine of 2.0 mg/dL
- D. Blood glucose of 150 mg/dL
Correct Answer: A
Rationale: A serum potassium level of 6.5 mEq/L is most concerning in a client with CKD as it indicates severe hyperkalemia, requiring immediate intervention. Hyperkalemia can lead to life-threatening cardiac arrhythmias. Serum sodium levels within the normal range (135 mEq/L) are not immediately concerning. Serum creatinine of 2.0 mg/dL may indicate impaired kidney function but does not require immediate intervention for hyperkalemia. Blood glucose of 150 mg/dL is within normal limits and does not directly correlate with hyperkalemia in this scenario.
When preparing to insert a nasogastric (NG) tube for a client admitted to the surgical unit with symptoms of a possible intestinal obstruction, which intervention should the nurse implement?
- A. Elevate the head of the bed 60 to 90 degrees
- B. Administer an antiemetic
- C. Prepare the client for surgery
- D. Provide oral care
Correct Answer: A
Rationale: Elevating the head of the bed to 60 to 90 degrees is essential when inserting an NG tube. This position helps facilitate the passage of the tube through the esophagus into the stomach and reduces the risk of aspiration. Administering an antiemetic may be necessary to control nausea or vomiting, but it is not the primary intervention when inserting an NG tube. Preparing the client for surgery is not indicated solely for the insertion of an NG tube. Providing oral care is important for maintaining oral hygiene but is not directly related to inserting an NG tube.
An adult female client with chronic kidney disease (CKD) asks the nurse if she can continue taking over-the-counter medications. Which medication provides the greatest threat to this client?
- A. Magnesium hydroxide (Maalox).
- B. Birth control pills.
- C. Cough syrup containing codeine.
- D. Cold medication containing alcohol.
Correct Answer: A
Rationale: The correct answer is A: Magnesium hydroxide (Maalox). In clients with CKD, magnesium can accumulate to toxic levels due to decreased excretion by the kidneys. Therefore, it poses the greatest threat to this client population. Choice B, birth control pills, is not typically contraindicated in CKD. Choice C, cough syrup containing codeine, may require dose adjustments but is not the greatest threat. Choice D, cold medication containing alcohol, is a concern mainly in liver disease, not CKD.