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A nurse is admitting a client who reports excessive thirst, fever, and periods of confusion. The nurse suspects the client is experiencing heat exhaustion. Which of the following electrolyte imbalances should the nurse expect?
- A. Hypernatremia
- B. Hypocalcemia
- C. Hyperkalemia
- D. Hyperphosphatemia
Correct Answer: A
Rationale: Heat exhaustion can lead to excessive sweating and dehydration, causing hypernatremia (elevated sodium levels) due to water loss.
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A nurse is assisting with the plan of care for a client who has aspiration pneumonia and hypoxia. Which of the following actions should the nurse plan to take?
- A. Initiate fall precautions.
- B. Apply petroleum jelly to the client's nares.
- C. Implement contact precautions.
- D. Maintain the client in a supine position.
Correct Answer: A
Rationale: Hypoxia increases fall risk due to weakness or confusion, making fall precautions essential in aspiration pneumonia care.
A nurse at a rehabilitation facility is contributing to the plan of care for a client who has had a below-the-knee amputation. Which of the following interventions should the nurse include in the plan of care?
- A. Restrict visitors to family members until the client is able to wear a prosthesis.
- B. Encourage the client to talk with another client who completed rehabilitation for amputation.
- C. Instruct the client to ignore phantom pain sensations.
- D. Suggest that family members bring clothing for the client from home.
- E. Ask the client to describe her feelings about the loss of the affected limb.
Correct Answer: B,D,E
Rationale: Peer support, familiar clothing, and addressing feelings promote psychological adjustment and rehabilitation; restricting visitors or ignoring phantom pain is not therapeutic.
Nurses' Notes
Vital Signs
Laboratory Results
Day 1, 1000:
The client reports mid abdominal pain. Client reports pain as 7 on a scale of 0 to 10. The client states, "I haven't had a bowel movement in 4 days." The client states, "I also have vomited once or twice."
Physical Exam:
General: uncomfortable, grimacing
HEENT: dry mucous membranes
Cardiovascular: S1, S2, no murmur
Respiratory: bilateral breath sounds clear
Gastrointestinal: tenderness to palpation, high-pitched bowel sounds
Skin: no jaundice noted
Social history: drinks 1 to 2 glasses of wine daily. Client reports no tobacco use.
The nurse is assisting with the care of a client. For each finding, click to specify if the finding is consistent with small bowel obstruction or acute pancreatitis. Each finding may support more than 1 disease process.
- A. Pain level
- B. Social history
- C. Skin findings
- D. Lipase level
- E. WBC count
- F. Abdominal findings
Correct Answer: A (small bowel obstruction, acute pancreatitis), B (acute pancreatitis), C (neither), D (acute pancreatitis), E (small bowel obstruction, acute pancreatitis), F (small bowel obstruction)
Rationale: Pain level and abdominal findings (tenderness, high-pitched bowel sounds) support small bowel obstruction and acute pancreatitis; social history (alcohol use) and lipase support pancreatitis; WBC count supports both; skin findings (no jaundice) support neither.
A nurse is contributing to the plan of care for a client following a total hip arthroplasty. Which of the following interventions should the nurse recommend?
- A. Turn the client every 4 hr for 48 hr while on bed rest.
- B. Have the client use an incentive spirometer every 4 hr.
- C. Instruct the client to bend from the hip when retrieving items from the floor.
- D. Maintain hip abduction when turning the client.
Correct Answer: D
Rationale: Maintaining hip abduction prevents dislocation of the new hip joint, a critical consideration post-hip arthroplasty.
A nurse is collecting data from a client about her current pain status. Which of the following questions should the nurse ask to determine the quality of the client's pain?
- A. Do you have any pain this morning?
- B. Is your pain the same as it has been?
- C. Could you rate your pain on a scale from 0 to 10?
- D. What does your pain feel like?
Correct Answer: D
Rationale: Asking 'What does your pain feel like?' assesses the quality (e.g., sharp, dull), a key component of pain assessment.