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A nurse is assessing a client who has a potassium level of 3.0 mEq/L. Which of the following findings should the nurse expect?
- A. Diarrhea
- B. Muscle weakness
- C. Hypertension
- D. Bradycardia
Correct Answer: B
Rationale: Muscle weakness is a common finding in clients with hypokalemia, as potassium is essential for proper muscle function. Diarrhea (choice A) is more commonly associated with hyperkalemia rather than hypokalemia. Hypertension (choice C) is not typically a direct result of low potassium levels. Bradycardia (choice D) is more commonly associated with hyperkalemia, not hypokalemia.
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A nurse is planning care for a client who has a new diagnosis of deep vein thrombosis (DVT). Which of the following interventions should the nurse include?
- A. Massage the affected extremity every 4 hours.
- B. Encourage the client to remain on bed rest.
- C. Apply cold packs to the affected extremity.
- D. Encourage the client to ambulate frequently.
Correct Answer: C
Rationale: The correct intervention for a client with deep vein thrombosis (DVT) is to apply cold packs to the affected extremity. Cold packs help reduce swelling and pain by causing vasoconstriction. Massaging the affected extremity could dislodge a clot, leading to serious complications. Encouraging bed rest may increase the risk of clot propagation, while frequent ambulation is contraindicated as it can dislodge clots.
A nurse is assessing a newborn's heart rate. Which of the following actions should the nurse take?
- A. Auscultate the apical pulse and count for 1 minute
- B. Place a sensor on the index finger
- C. Heat the skin prior to placing the probe
- D. Recheck after 10 minutes
Correct Answer: A
Rationale: Corrected Rationale: Auscultating the apical pulse and counting for one minute is the appropriate method to accurately measure a newborn's heart rate. The apical pulse is located at the point of maximum impulse (PMI), which is usually at the fourth or fifth intercostal space along the mid-clavicular line. This method allows for a precise assessment of the newborn's heart rate. Choice B, placing a sensor on the index finger, is incorrect because this method is more suitable for measuring oxygen saturation rather than heart rate. Choice C, heating the skin prior to placing the probe, is unnecessary for assessing heart rate and may lead to potential burns in newborns. Choice D, rechecking after 10 minutes, is not appropriate as immediate assessment and intervention may be required if an abnormal heart rate is detected in a newborn.
A patient is diagnosed with deep vein thrombosis (DVT). Which of the following actions should the nurse take?
- A. Massage the affected extremity every 2 hours.
- B. Encourage the patient to ambulate as soon as possible.
- C. Apply warm compresses to the affected extremity.
- D. Elevate the affected extremity.
Correct Answer: D
Rationale: Elevating the affected extremity is crucial in managing deep vein thrombosis (DVT) as it helps reduce swelling and promotes venous return, thereby preventing further complications such as pulmonary embolism. Massaging the affected extremity can dislodge a clot and lead to serious consequences. While ambulation is important, in DVT, early ambulation without elevation can potentially dislodge the clot. Warm compresses can increase blood flow to the area and worsen the condition by promoting clot dislodgement.
A client at risk for osteoporosis is being taught by a nurse about dietary measures to increase calcium intake. Which of the following foods should the nurse recommend?
- A. Carrots
- B. Cottage cheese
- C. Bananas
- D. Broccoli
Correct Answer: D
Rationale: The correct answer is D: Broccoli. Broccoli is high in calcium, making it a suitable recommendation for clients at risk for osteoporosis. Carrots, Cottage cheese, and Bananas are not significant sources of calcium compared to broccoli, and therefore, they are not the best choices to increase calcium intake.
A nurse is reviewing the results of an arterial blood gas analysis of a client who has chronic obstructive pulmonary disease. Which of the following results should the nurse expect?
- A. PaO2 of 95 mm Hg
- B. PaCO2 of 55 mm Hg
- C. HCO3 of 24 mEq/L
- D. pH level of 7.35
Correct Answer: B
Rationale: In chronic obstructive pulmonary disease, there is impaired gas exchange, leading to retention of carbon dioxide (CO2) and subsequent respiratory acidosis. A PaCO2 of 55 mm Hg is higher than the normal range (35-45 mm Hg) and is indicative of respiratory acidosis in COPD. Choices A, C, and D are not typically associated with COPD. PaO2 may be decreased, HCO3 may be elevated to compensate for acidosis, and pH may be lower than 7.35 due to respiratory acidosis in COPD.