Nokea
A male college student is brought to an emergency clinic by his friends because they report that he has been vomiting for the past two days as a result of food poisoning. Laboratory findings indicate that the client's potassium level is 2.5 mEq/L (2.5 mmol/L), so he is admitted to a local hospital. Which intervention is most important for the nurse to include in this client's plan of care?
- A. Monitor client's electrocardiogram continuously.
- B. Inject prescribed potassium chloride IV push slowly.
- C. Assess level of consciousness every 4 hours.
- D. Instruct client on dietary intake of potassium-rich foods.
Correct Answer: A
Rationale: Continuous ECG monitoring is critical due to hypokalemia's risk of causing life-threatening arrhythmias.
You may also like to solve these questions
An adult male is transferred from post anesthesia care unit (PACU) to the postoperative unit following an internal fixation of a fractured tibia and fibula that occurred during a motor vehicle collision (MVC). The nurse reports that the client received morphine 2 mg intravenously 45 minutes ago and is currently experiencing pain relief of 7 from a previous report of 10. Postoperative prescriptions include, start patient-controlled analgesia (PCA) using hydromorphone 0.2 mg on demand and 0.2 mg/hour basal rate. Which client information should the nurse provide to complete this report?
- A. Police department wants to be notified when the client is alert.
- B. Neurovascular assessments below the fracture are normal.
- C. No nausea or vomiting during the PACU recovery stay.
- D. The family is requesting a private room when one is available.
Correct Answer: B
Rationale: Normal neurovascular assessments are critical to ensure no complications post-surgery.
An older client who had a hernia repair 12 hours ago suddenly becomes agitated, pulls out the intravenous (IV) catheter, and staggers out into the corridor, demanding to be set free. The nurse assists the client back to bed and re-establishes the IV access. Which intervention is most important for the nurse to implement prior to leaving the client's room?
- A. Discuss with the family about placing the client in a skilled care facility.
- B. Determine if the client is manifesting other neurologic changes.
- C. Apply a restraining device to prevent the client from self injury.
- D. Request family members report when the client is left alone.
Correct Answer: B
Rationale: Assessing for neurologic changes identifies potential causes of agitation, such as delirium or hypoxia.
Several family members are visiting a client who had a myocardial infarction 4 days ago. The unlicensed assistive personnel (UAP) informs the nurse that one of the visitors is lying on the client's bed. Which action should the nurse implement?
- A. Discuss why visitors should not lie in the bed with the client.
- B. Notify the charge nurse that the visitor is lying on the client's bed.
- C. Explain that the client has the right to have a visitor lie on the bed.
- D. Instruct the UAP to ask the visitor to get off the client's bed.
Correct Answer: D
Rationale: Instructing the UAP to address the visitor maintains hygiene and safety efficiently.
A fire is reported in the kitchen on the first floor of a three-floor community hospital, and the operator notifies the charge nurse on the third floor to start evacuation procedures. Which intervention should the charge nurse implement?
- A. Instruct the nursing staff to evacuate ambulatory clients to the nearest fire exits.
- B. Instruct unlicensed assistive personnel (UAPs) to transfer all non-ambulatory clients via wheelchairs.
- C. Announce in a calm voice that all visitors should proceed immediately to the first floor via the service elevators.
- D. Shut all doors to client rooms and tell everyone to stay in their rooms until the fire department arrives.
Correct Answer: A
Rationale: Evacuating ambulatory clients to fire exits prioritizes their safety, following standard fire evacuation protocols.
The charge nurse, working with one nurse, two practical nurses (PNs), a unit secretary, and two unlicensed assistive personnel (UAPs), is caring for 24 clients on a medical surgical unit. Which task is best for the charge nurse to assign to the PN?
- A. Transcription of the healthcare provider's treatment plan for a client transferred from a critical care unit.
- B. The subclavian dressing change on a client diagnosed with inflammatory bowel disease.
- C. The admission assessment of a client diagnosed with bacterial pneumonia.
- D. The insertion of a Foley catheter for a client diagnosed with septicemia.
Correct Answer: D
Rationale: Foley catheter insertion is within the PN's scope, a task-based procedure suitable for their training.