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A healthcare professional is reviewing the medical record of a client who is receiving furosemide. Which of the following laboratory values should the healthcare professional monitor while the client is taking this medication?
- A. Sodium
- B. Glucose
- C. Potassium
- D. Calcium
Correct Answer: C
Rationale: The correct answer is C: Potassium. Furosemide is a diuretic that can cause potassium depletion due to increased urinary excretion. Monitoring potassium levels is crucial to prevent hypokalemia, which can lead to serious complications such as cardiac arrhythmias. Sodium (choice A) levels are not typically affected by furosemide. Glucose (choice B) monitoring is important with other medications like corticosteroids but is not directly related to furosemide use. Calcium (choice D) levels are not significantly impacted by furosemide.
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A nurse is preparing to insert an indwelling urinary catheter for a female client. Which of the following actions should the nurse take?
- A. Use sterile gloves
- B. Lubricate the catheter with water
- C. Insert the catheter using clean technique
- D. Open the catheterization kit away from the body
Correct Answer: D
Rationale: The correct action for the nurse to take when preparing to insert an indwelling urinary catheter is to open the catheterization kit away from the body. This is crucial to maintain the sterility of the kit and the procedure. Using sterile gloves (Choice A) is important, but it is not specific to this step. Lubricating the catheter with water (Choice B) is incorrect as it should be lubricated with a water-soluble lubricant. Inserting the catheter using clean technique (Choice C) is incorrect as indwelling urinary catheter insertion requires sterile technique to prevent infections.
A client with a sprained right ankle is learning to walk with a cane. What action demonstrates effective teaching?
- A. The client advances the cane 18 inches in front of the foot
- B. The client holds the cane in the left hand
- C. The client advances the cane and the right leg simultaneously
- D. The client holds the cane with the elbow flexed at 60°
Correct Answer: B
Rationale: When a client has a sprained right ankle, they should hold the cane in the opposite hand (left hand) to the affected leg for better support and balance. This positioning helps to reduce the weight on the injured leg while providing stability. Option A is incorrect because advancing the cane too far in front can lead to loss of balance. Option C is incorrect as it does not provide the necessary support for the injured leg. Option D is incorrect as the elbow should be slightly flexed but not necessarily at a specific angle.
What are the key factors in assessing a patient's fall risk?
- A. Assess the patient's age and mobility
- B. Evaluate the patient's medication list for sedatives
- C. Assess the patient's vision and hearing
- D. Check for recent falls and cognitive impairment
Correct Answer: A
Rationale: The correct answer is A. Assessing the patient's age and mobility are key factors in determining fall risk. Age can affect balance and reaction time, while mobility influences the patient's stability. Choices B, C, and D are important considerations in assessing a patient's fall risk as well, but age and mobility play a more direct role in determining the patient's susceptibility to falls.
Which intervention is essential when caring for a client with heart failure on fluid restriction?
- A. Encourage the client to drink water throughout the day
- B. Monitor the client's weight daily to assess fluid balance
- C. Limit fluid intake during meals
- D. Weigh the client once a week to assess fluid balance
Correct Answer: B
Rationale: The correct answer is B: 'Monitor the client's weight daily to assess fluid balance.' When caring for a client with heart failure on fluid restriction, it is essential to monitor their weight daily to evaluate fluid balance accurately. This helps healthcare providers assess if the client is retaining excess fluid, a common issue in heart failure. Choices A, C, and D are incorrect. Encouraging the client to drink water throughout the day contradicts fluid restriction. Limiting fluid intake during meals may not provide a comprehensive assessment of fluid balance, and weighing the client once a week is not frequent enough to detect rapid changes in fluid status that could worsen heart failure symptoms.
A nurse is collecting data from a school-age child who has sustained a skull fracture. Which of the following is a manifestation of increased intracranial pressure?
- A. Nausea
- B. Confusion about own name
- C. Rapid pulse
- D. Vomiting
Correct Answer: B
Rationale: Confusion, especially about one's own name, is a sign of increased intracranial pressure and should be addressed. Nausea and vomiting are common symptoms of increased intracranial pressure, but confusion about personal information is a more specific and critical indication that requires immediate attention. Rapid pulse may be a possible response to increased intracranial pressure, but it is not as specific as confusion about own name in this scenario.