Nokea
A nurse is caring for a client in preterm labor who is receiving magnesium sulfate by continuous IV infusion. Which of the following client findings indicates medication toxicity?
- A. Blood glucose of 150 mg/dL
- B. Urine output of 20 mL per hour
- C. Systolic blood pressure of 140 mm Hg
- D. BUN 20 mg/dL
Correct Answer: B
Rationale: A urine output of 20 mL per hour is low and indicates renal insufficiency, a sign of magnesium sulfate toxicity. The medication is excreted by the kidneys, so toxicity can occur if renal function declines. Blood glucose of 150 mg/dL is within normal range and not indicative of magnesium sulfate toxicity. A systolic blood pressure of 140 mm Hg is elevated but not specifically related to magnesium sulfate toxicity. A BUN level of 20 mg/dL is also within normal limits and not a sign of medication toxicity.
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A client who is having suicidal thoughts tells the nurse, "It just doesn't seem worth it anymore. Why not end my misery?" Which of the following responses by the nurse is appropriate?
- A. Why do you think your life is not worth it anymore?
- B. Do you have a plan to end your life?
- C. I need to know what you mean by misery
- D. You can trust me and tell me what you're thinking
Correct Answer: B
Rationale: The appropriate response by the nurse is to ask about the client's plan to end their life. This question helps to assess the severity of the client's suicidal ideation and the immediacy of the risk, allowing the nurse to determine the appropriate level of intervention. Choices A, C, and D do not directly address the immediate risk assessment needed in this situation.
A nurse is caring for a client who has DVT. Which of the following instructions should the nurse include in the plan of care?
- A. Limit the client's fluid intake to 1500 mL per day
- B. Massage the affected extremity to relieve pain
- C. Apply cold packs to the affected extremity
- D. Elevate the client's affected extremity when in bed
Correct Answer: D
Rationale: The correct instruction the nurse should include in the plan of care for a client with DVT is to elevate the affected extremity when in bed. Elevating the affected extremity helps improve venous return, reduces edema, alleviates discomfort, and promotes healing in clients with DVT. Limiting fluid intake can be detrimental as adequate hydration is important for circulation. Massaging the affected extremity can dislodge clots and worsen the condition. Applying cold packs can cause vasoconstriction, which is not recommended for DVT as it can impede blood flow further.
A nurse is caring for a client who repeatedly refuses meals. The nurse overhears an assistive personnel telling the client, "If you don't eat, I'll put restraints on your wrists and feed you." The nurse should intervene and explain to the AP that this statement constitutes which of the following torts?
- A. Assault
- B. Battery
- C. Malpractice
- D. Negligence
Correct Answer: A
Rationale: The correct answer is A: Assault. Assault is the act of threatening a client with harm, such as the threat of using restraints to force-feed the client, even if no physical contact occurs. In this scenario, the statement made by the assistive personnel constitutes assault because it involves the threat of harm. Choice B, Battery, involves actual physical contact without the client's consent, which is not present in the scenario. Choice C, Malpractice, refers to professional negligence or misconduct, not a direct threat to the client. Choice D, Negligence, involves failure to provide reasonable care that results in harm, which is not applicable in this context.
While caring for a newborn under phototherapy lights, what is an appropriate nursing action?
- A. Ensure an eye shield is covering the eyes
- B. Apply lotion to the exposed skin
- C. Offer glucose water between feedings
- D. Discontinue breastfeeding during treatment
Correct Answer: A
Rationale: The correct answer is to ensure an eye shield is covering the eyes. This action is essential to protect the newborn's eyes from the bright light used in phototherapy. Applying lotion to the exposed skin (Choice B) is not necessary and may interfere with the treatment. Offering glucose water between feedings (Choice C) is not indicated and may not be appropriate for a newborn undergoing phototherapy. Discontinuing breastfeeding during treatment (Choice D) is not recommended as breastfeeding should be continued unless contraindicated.
A nurse is assessing a client who has a blood glucose level of 250 mg/dL. Which of the following clinical manifestations is associated with this finding?
- A. Confusion
- B. Thirst
- C. Diaphoresis
- D. Shakiness
Correct Answer: B
Rationale: Corrected Detailed Rationale: A blood glucose level of 250 mg/dL indicates hyperglycemia. Thirst (polydipsia) is a common clinical manifestation associated with hyperglycemia. The body tries to compensate for the high blood sugar by increasing fluid intake. Confusion (choice A) is more commonly associated with hypoglycemia, not hyperglycemia. Diaphoresis (choice C) and shakiness (choice D) are typical manifestations of hypoglycemia, not hyperglycemia. Therefore, the correct answer is increased thirst (polydipsia) in response to the elevated blood glucose level.