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A nurse is assessing a client who has a sodium level of 125 mEq/L. Which of the following findings should the nurse expect?
- A. Increased appetite
- B. Dry mucous membranes
- C. Hypotension
- D. Hyperreflexia
Correct Answer: C
Rationale: A sodium level of 125 mEq/L indicates hyponatremia, which can lead to hypotension. Hyponatremia is associated with signs such as confusion and weakness, rather than increased appetite, dry mucous membranes, or hyperreflexia. Therefore, the nurse should expect hypotension as a finding in a client with a sodium level of 125 mEq/L.
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A nurse is planning care for a client who has chronic obstructive pulmonary disease (COPD). Which of the following interventions should the nurse include?
- A. Encourage the client to take deep breaths.
- B. Administer oxygen as needed.
- C. Teach the client pursed-lip breathing.
- D. Limit the client's fluid intake.
Correct Answer: C
Rationale: The correct intervention for a client with COPD is to teach pursed-lip breathing. This technique helps improve oxygenation and reduce dyspnea by promoting better air exchange in the lungs. Encouraging deep breaths may not be suitable for clients with COPD as it can lead to air trapping. Administering oxygen is important in COPD, but teaching pursed-lip breathing is a more direct intervention to help the client manage their condition. Limiting fluid intake is not a standard intervention for COPD and may not be relevant to improving respiratory status.
When caring for a client with a new prescription for enoxaparin for the prevention of DVT, what is an appropriate action by the nurse?
- A. Expel any air bubbles at the top of the prefilled syringe
- B. Massage the injection site to evenly distribute the medication
- C. Inject the medication into the lateral abdominal wall
- D. Administer an NSAID for injection site discomfort
Correct Answer: C
Rationale: When administering enoxaparin for the prevention of DVT, the nurse should inject the medication into the lateral abdominal wall. This site is preferred for subcutaneous injections of enoxaparin to reduce the risk of bleeding or injury. Expelling air bubbles, massaging the injection site, or administering an NSAID for discomfort are not appropriate actions and could lead to complications or ineffective medication delivery.
What is the priority nursing action for a patient with respiratory distress?
- A. Administer oxygen
- B. Reposition the patient
- C. Administer bronchodilators
- D. Provide chest physiotherapy
Correct Answer: A
Rationale: The priority nursing action for a patient with respiratory distress is to administer oxygen. Oxygen therapy is crucial in improving oxygenation levels and relieving respiratory distress, making it the top priority intervention. Repositioning the patient, administering bronchodilators, or providing chest physiotherapy may be necessary interventions depending on the underlying cause, but ensuring adequate oxygen supply should take precedence in addressing respiratory distress.
Which laboratory test is essential for monitoring renal function in a patient with chronic kidney disease?
- A. Monitor BUN and creatinine levels
- B. Check blood glucose levels
- C. Monitor hemoglobin and hematocrit levels
- D. Monitor liver enzymes
Correct Answer: A
Rationale: The correct answer is to monitor BUN (Blood Urea Nitrogen) and creatinine levels in a patient with chronic kidney disease. These tests provide crucial information about renal function. Checking blood glucose levels (Choice B) is important for monitoring diabetes, not renal function. Monitoring hemoglobin and hematocrit levels (Choice C) helps assess anemia, not specifically renal function. Monitoring liver enzymes (Choice D) is relevant for assessing liver function, not renal function.
A nurse is planning care for a client who is postoperative following a laminectomy. Which of the following interventions should the nurse include in the plan of care?
- A. Elevate the client's legs while in bed.
- B. Reposition the client every 2 hours.
- C. Maintain bed rest for the first 24 hours postoperatively.
- D. Ambulate the client on the first postoperative day.
Correct Answer: D
Rationale: Ambulating the client on the first postoperative day is crucial to prevent complications like deep vein thrombosis and aid in the recovery process. Elevating the legs while in bed can help with circulation but is not as effective in preventing complications related to immobility post-surgery. Repositioning every 2 hours is important for preventing pressure ulcers but does not directly address postoperative care. Maintaining bed rest for the first 24 hours postoperatively can increase the risk of complications associated with immobility, making early ambulation a more appropriate intervention.