Nokea
A gravida 2 para 1 client is hospitalized with severe preeclampsia. While she receives magnesium sulfate (MgSO4) therapy, the nurse knows it is safe to repeat the dosage if:
- A. Deep tendon reflexes are absent
- B. Urine output is 20 mL/hr
- C. MgSO4 serum levels are >15 mg/dL
- D. Respirations are >16 breaths/min
Correct Answer: D
Rationale: Respirations >16 breaths/min indicate that toxic magnesium levels have not been reached, making it safe to repeat the dose.
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While changing the dressing on a client's central line, the nurse notices redness and warmth at the needle insertion site. Which of the following actions would be appropriate to implement based on this finding?
- A. Discontinue the central line.
- B. Begin a peripheral IV.
- C. Document in the nurse's notes and notify the physician after redressing the site.
- D. Clean the site well and redress.
Correct Answer: C
Rationale: The nurse should always document findings and alert the physician to the findings as well. The physician may then initiate a new central line and order the current central line to be discontinued.
The physician of an alcoholic client places him on a low-protein, high-carbohydrate diet. When choosing his menu, the client's best choice from the items below would be:
- A. Liver and onions, macaroni and cheese, tea with sugar
- B. Baked chicken, baked potato with bacon bits, milk
- C. Waffles with butter and honey, orange juice
- D. Cheese omelette with ham and mushrooms, milk
Correct Answer: C
Rationale: Serum ammonia levels can be decreased by restricting dietary protein intake. Waffles, honey, and orange juice are high in carbohydrate and low or completely lacking in protein. Butter, a concentrated fat, will provide extra calories.
The nurse is caring for a client with a history of a stroke who has dysphagia. The nurse should:
- A. Offer thin liquids
- B. Position the client upright for meals
- C. Feed the client quickly
- D. Use a straw for fluids
Correct Answer: B
Rationale: Positioning upright during meals reduces aspiration risk in dysphagia post-stroke. Thickened liquids, slow feeding, and avoiding straws are also recommended.
After 3 weeks of treatment, a severely depressed client suddenly begins to feel better and starts interacting appropriately with other clients and staff. The nurse knows that this client has an increased risk for:
- A. Suicide
- B. Exacerbation of depressive symptoms
- C. Violence toward others
- D. Psychotic behavior
Correct Answer: A
Rationale: When the severely depressed client suddenly begins to feel better, it often indicates that the client has made the decision to kill himself or herself and has developed a plan to do so. Improvement in behavior is not indicative of an exacerbation of depressive symptoms. The depressed client has a tendency for self-violence, not violence toward others. Depressive behavior is not always accompanied by psychotic behavior.
During the change of shift report, a nurse writes in her notes that she suspects illegal drug use by a client assigned to her care. During the shift, the notes are found by the client's daughter. The nurse could be sued for:
- A. Libel
- B. Slander
- C. Malpractice
- D. Negligence
Correct Answer: A
Rationale: Libel involves written defamatory statements, such as unverified suspicions of drug use in notes accessible to others, potentially harming the client's reputation.