Nokea
A nurse in the emergency department is assisting with the care of a client who is comatose. The provider suspects ketoacidosis. Which of the following findings should the nurse expect?
- A. Cheyne-Stokes breathing.
- B. Malignant hypertension.
- C. Acetone odor to breath.
- D. Blood glucose level below 40 mg/dL.
Correct Answer: C
Rationale: An acetone odor to the breath is a classic sign of diabetic ketoacidosis, occurring due to the accumulation of ketones in the blood.
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A nurse is reinforcing teaching with a client who takes furosemide and has a serum potassium level of 3.1 mEq/L. Which of the following foods should the nurse instruct the client to include in his daily diet?
- A. Cabbage.
- B. Cheddar cheese.
- C. Bananas.
- D. Potatoes.
Correct Answer: C
Rationale: Bananas are high in potassium, helping to increase serum potassium levels, which is beneficial for clients taking furosemide, a diuretic that causes potassium loss.
A nurse is preparing to administer levothyroxine 275 mcg PO to a client. The amount available is levothyroxine 137 mcg/tablet. How many tablets should the nurse administer?
- B. 1 tablet
- C. 3 tablets
- D. 4 tablets
Correct Answer: 2 tablets
Rationale: 275 mcg ÷ 137 mcg/tablet = 2.007 tablets, rounded to 2 tablets.
A nurse is assisting a client who is postoperative following a total hip arthroplasty into a supine position. Which of the following actions is appropriate to prevent hip dislocation?
- A. Place a sandbag to the lateral calf.
- B. Place a wedge pillow between the legs.
- C. Place a trochanter roll against the thigh.
- D. Place a footboard on the bed.
Correct Answer: B
Rationale: Placing a wedge pillow between the legs maintains hip abduction, preventing adduction and reducing the risk of dislocation after hip arthroplasty.
A nurse is assisting with the care of a client who has hypertension and chronic kidney disease. The client is scheduled for hemodialysis. Which of the following actions should the nurse plan to take while caring for this client? (Select all that apply.)
- A. Obtain the client's weight.
- B. Verify the glomerular filtration rate.
- C. Check the graft site for a palpable thrill.
- D. Document vital signs.
- E. Administer a sedative to the client.
Correct Answer: A,C,D
Rationale: Obtaining the client's weight, checking the graft site for a palpable thrill, and documenting vital signs are essential to monitor fluid balance, ensure vascular access functionality, and detect complications during hemodialysis.
A nurse is reinforcing teaching with a middle-aged client about hypertension. Which of the following information should the nurse include in the teaching?
- A. Plan to have potassium blood levels checked when taking thiazide diuretics.
- B. Limit alcohol consumption to 3 drinks a day when hypertensive.
- C. Set your goal body weight within 25% of ideal body weight.
- D. Plan to lower sodium intake to 3,000 mg each day.
Correct Answer: A
Rationale: Monitoring potassium levels is essential with thiazide diuretics, which can cause hypokalemia, ensuring safe management of hypertension.