Nokea
A nurse is caring for a client who has chronic kidney disease and a serum potassium level of 6.5 mEq/L. Which of the following actions should the nurse take?
- A. Administer sodium bicarbonate
- B. Administer sodium polystyrene sulfonate
- C. Administer calcium gluconate
- D. Administer calcium carbonate
Correct Answer: B
Rationale: The correct action for the nurse to take is to administer sodium polystyrene sulfonate. This medication promotes potassium excretion and helps lower serum potassium levels in clients with hyperkalemia, which is indicated by a high potassium level. Sodium bicarbonate (choice A) is not used to treat hyperkalemia. Calcium gluconate (choice C) and calcium carbonate (choice D) are used to manage hyperkalemia by stabilizing cell membranes but are not the initial treatment choice for lowering potassium levels.
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A healthcare provider is assessing a client who has bacterial meningitis. Which of the following findings should the healthcare provider expect?
- A. Nuchal rigidity.
- B. Flaccid paralysis.
- C. Bradycardia.
- D. Hypothermia.
Correct Answer: A
Rationale: Nuchal rigidity is a classic sign of bacterial meningitis and indicates inflammation of the meninges. It is characterized by neck stiffness and pain upon neck flexion. Flaccid paralysis (Choice B) is not typically associated with bacterial meningitis but rather conditions like Guillain-Barre syndrome. Bradycardia (Choice C) and hypothermia (Choice D) are not commonly seen in bacterial meningitis; instead, patients may present with fever, tachycardia, and signs of systemic inflammation.
A client who has a new prescription for lithium is receiving teaching from a nurse. Which of the following statements by the client indicates an understanding of the teaching?
- A. ''I will avoid eating foods that contain tyramine.''
- B. ''I should increase my salt intake while taking this medication.''
- C. ''I should drink at least 2 liters of water each day while taking this medication.''
- D. ''I should avoid consuming caffeinated beverages while taking this medication.''
Correct Answer: C
Rationale: The correct answer is C. Drinking at least 2 liters of water daily is crucial for clients taking lithium to prevent dehydration and lithium toxicity. Lithium is a salt, so it's important for clients to maintain adequate hydration. Option A is incorrect because lithium does not interact with tyramine-containing foods. Option B is incorrect because increasing salt intake is not necessary and can actually exacerbate lithium toxicity. Option D is incorrect because avoiding caffeinated beverages is not a priority teaching point for clients taking lithium.
When collecting a sputum specimen from a client with tuberculosis, what action should the nurse take?
- A. Obtain the specimen immediately upon the client waking up.
- B. Wait one day to collect the specimen if the client cannot provide sputum.
- C. Ask the client to provide 15 to 20 ml of sputum.
- D. Wear sterile gloves when collecting the specimen.
Correct Answer: A
Rationale: The correct answer is to obtain the specimen immediately upon the client waking up. Collecting sputum early in the morning provides the best sample for tuberculosis testing. Option B is incorrect because waiting a day can decrease the accuracy of the specimen. Option C is incorrect as it does not specify the optimal timing for specimen collection. Option D is incorrect as sterile gloves should be worn for infection control but do not specifically relate to the timing of specimen collection.
A nurse is caring for a client who is newly diagnosed with pancreatic cancer and has questions about the disease. To research, the nurse should identify which of the following electronic databases has the most comprehensive collection of nursing articles?
- A. MEDLINE
- B. CINAHL
- C. ProQuest
- D. Health Source
Correct Answer: B
Rationale: The correct answer is B, CINAHL. CINAHL is specifically dedicated to nursing and allied health literature, making it the most appropriate database for nursing articles and research. It provides a comprehensive collection of nursing-related articles, journals, and research studies, which are essential for evidence-based practice. MEDLINE, on the other hand, is a valuable resource for medical literature but is not as nursing-focused as CINAHL. ProQuest and Health Source cover a wider range of subjects beyond nursing, so they are not as comprehensive when it comes to nursing-specific articles and research. Therefore, for the nurse looking to access a database with a vast collection of nursing articles, CINAHL is the most suitable option.
A client who has a new diagnosis of type 2 diabetes mellitus is being taught about foot care by a nurse. Which of the following statements should the nurse include?
- A. Use lotion on your feet to prevent dry, cracked skin, avoiding application between the toes.
- B. Avoid soaking your feet in warm water daily to prevent dry skin.
- C. Trim your toenails straight across to prevent injury.
- D. Do not apply a heating pad to your feet if they feel cold.
Correct Answer: C
Rationale: The correct answer is C. Trimming toenails straight across is essential for clients with diabetes to prevent the risk of ingrown toenails and injury. Using lotion on feet can be beneficial but should not be applied between the toes to avoid moisture buildup, which can lead to infections. Soaking feet in warm water can lead to dry skin, increasing the risk of cracks and other complications. Applying a heating pad to feet when they feel cold is not recommended for clients with diabetes due to impaired sensation, which can result in burns and other injuries.