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A newly admitted patient is diagnosed with hyponatremia. When making room assignments, the charge nurse should take which action?
- A. Assign the patient to a room near the nurse's station.
- B. Place the patient in a room nearest to the water fountain.
- C. Place the patient on telemetry to monitor for peaked T waves.
- D. Assign the patient to a semi-private room and place an order for a low-salt diet.
Correct Answer: A
Rationale: The correct answer is A. The patient should be placed near the nurse's station if confused to allow close monitoring by the staff. To help improve serum sodium levels, water intake is restricted, so a patient with hyponatremia should not be placed near a water fountain. Peaked T waves are a sign of hyperkalemia, not hyponatremia, so telemetry for this purpose is unnecessary. Placing a confused patient in a semi-private room could be disruptive to the other patient. Additionally, the patient needs sodium replacement, not a low-salt diet.
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The nurse requests a meal tray for a client who follows Mormon beliefs and who is on a clear liquid diet following abdominal surgery. Which menu items should the nurse request for this client? (Select all that apply)
- A. apple juice
- B. black coffee
- C. orange juice
- D. hot chocolate
Correct Answer: A
Rationale: The correct answer is A: apple juice. Clear liquids like apple juice and orange juice are suitable for a client following a clear liquid diet and Mormon beliefs. Options B and D, black coffee and hot chocolate, contain caffeine, which may not align with the client's religious dietary restrictions. Therefore, these options should be avoided for this client.
The nurse is caring for a patient who has a central venous access device (CVAD). Which action by the nurse is appropriate?
- A. Avoid using friction when cleaning around the CVAD insertion site.
- B. Use the push-pause method to flush the CVAD after giving medications.
- C. Obtain an order from the healthcare provider to change the CVAD dressing.
- D. Position the patient's face away from the CVAD during injection cap changes.
Correct Answer: B
Rationale: The correct answer is B because using the push-pause method to flush the CVAD after giving medications helps remove debris from the CVAD lumen and decreases the risk for clotting. Choice A is incorrect because friction should be used when cleaning the CVAD insertion site to decrease infection risk. Choice C is incorrect because obtaining an order from the healthcare provider to change the CVAD dressing is not necessary; the dressing should be changed when damp, loose, or visibly soiled. Choice D is incorrect because the patient should face away from the CVAD during cap changes to minimize the risk of contamination.
A postoperative patient who had surgery for a perforated gastric ulcer has been receiving nasogastric suction for 3 days. The patient now has a serum sodium level of 127 mEq/L (127 mmol/L). Which prescribed therapy should the nurse question?
- A. Infuse 5% dextrose in water at 125 mL/hr.
- B. Administer IV morphine sulfate 4 mg every 2 hours PRN.
- C. Give IV metoclopramide (Reglan) 10 mg every 6 hours PRN for nausea.
- D. Administer 3% saline if serum sodium decreases to less than 128 mEq/L.
Correct Answer: A
Rationale: The nurse should question the prescription to infuse 5% dextrose in water at 125 mL/hr because the patient's gastric suction has been depleting electrolytes, leading to hyponatremia. Therefore, the IV solution should include electrolyte replacement. Solutions like lactated Ringer's solution would usually be ordered. The other choices (B, C, and D) are appropriate for a postoperative patient with gastric suction, addressing pain management, nausea control, and correcting hyponatremia if it drops below a certain level.
A male client with unstable angina needs a cardiac catheterization. So the healthcare provider explains the risks and benefits of the procedure and then leaves to set up for the procedure. When the nurse presents the consent form for signature, the client hesitates and asks how the wires will keep his heart going. Which action should the nurse take?
- A. Answer the client's specific questions with a short, understandable explanation
- B. Postpone the procedure until the client understands the risks and benefits
- C. Call the client's next of kin and ask them to provide verbal consent
- D. Page the healthcare provider to return and provide additional explanation
Correct Answer: D
Rationale: The correct action for the nurse to take in this situation is to page the healthcare provider to return and provide additional explanation. It is crucial for the client to have a clear understanding of the procedure, including its risks and benefits, before signing the consent form. While the nurse can provide general information, the detailed explanation of how the procedure works and its effects should come from the healthcare provider who will perform the procedure. Postponing the procedure until the client understands is appropriate, but the immediate need is to clarify the client's concerns with the healthcare provider. Calling the client's next of kin for verbal consent is not the correct course of action as the client is present and able to provide consent after receiving adequate information.
A patient who is taking a potassium-wasting diuretic for the treatment of hypertension complains of generalized weakness. It is most appropriate for the nurse to take which action?
- A. Assess for facial muscle spasms.
- B. Ask the patient about loose stools.
- C. Suggest that the patient avoid orange juice with meals.
- D. Ask the healthcare provider to order a basic metabolic panel.
Correct Answer: D
Rationale: Generalized weakness is a sign of hypokalemia, a potential side effect of potassium-wasting diuretics. By requesting a basic metabolic panel, the nurse can assess the patient's potassium levels. Facial muscle spasms are associated with hypocalcemia, not hypokalemia. Advising the patient to avoid orange juice, which is high in potassium, would be counterproductive if the patient is hypokalemic. Loose stools are typically seen in hyperkalemia, not hypokalemia.