Nokea
A nurse is caring for a client who has hypertension and has a potassium level of 6.8 mEq/L. Which of the following actions should the nurse take?
- A. Obtain a 12-lead ECG.
- B. Suggest that the client use a salt substitute.
- C. Ask the client to add citrus juices and bananas to her diet.
- D. Obtain a blood sample for a serum sodium level.
Correct Answer: A
Rationale: The correct answer is A: Obtain a 12-lead ECG. A potassium level of 6.8 mEq/L is significantly elevated (normal range is 3.5-5.0 mEq/L) and can lead to serious cardiac complications, such as arrhythmias. Therefore, obtaining an ECG is crucial to assess the client's cardiac status. Choice B (salt substitute) is incorrect as it can further elevate potassium levels. Choice C (citrus juices and bananas) is incorrect as these are high-potassium foods that should be avoided. Choice D (serum sodium level) is irrelevant to the client's elevated potassium level.
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A nurse is preparing to turn a client who is obese following a spinal fusion. The nurse should plan to use which of the following techniques to turn this client?
- A. Draw sheet
- B. Log roll
- C. Sliding board
- D. Hoyer lift
Correct Answer: B
Rationale: The correct answer is B: Log roll. When turning an obese client following spinal fusion, using a log roll technique is most appropriate. This technique involves turning the client as a single unit to prevent twisting or bending of the spine, reducing the risk of injury. The nurse should assist the client by coordinating the movement with other staff members to ensure a smooth and safe transition. The other choices are not suitable for this scenario: A) Draw sheet is typically used for moving a client up in bed, not for turning an obese client after spinal fusion. C) Sliding board is used for transferring clients from one surface to another, not for turning in bed. D) Hoyer lift is used for lifting and transferring clients who are unable to bear weight, not for turning a client in bed.
A nurse is caring for a client who has prostate cancer. The nurse should expect the provider to prescribe which of the following medications for this client?
- A. Tamoxifen
- B. Leuprolide
- C. Finasteride
- D. Cyclophosphamide
Correct Answer: B
Rationale: The correct answer is B: Leuprolide. Leuprolide is a gonadotropin-releasing hormone agonist that suppresses testosterone production, which can help slow the growth of prostate cancer. Tamoxifen (A) is used for breast cancer, Finasteride (C) is used for benign prostatic hyperplasia, and Cyclophosphamide (D) is a chemotherapy drug for various cancers. Therefore, in this case, the most appropriate medication for prostate cancer would be Leuprolide (B).
A nurse at an ophthalmology clinic is providing teaching to a client who has open-angle glaucoma and a new treatment regimen of timolol and pilocarpine eye drops. Which of the following instructions should the nurse provide?
- A. Administer the medications 5 minutes apart.
- B. Hold pressure on the conjunctival sac for 2 minutes following application of drops.
- C. It is not necessary to remove contact lenses before administering medications.
- D. Administer the medications by touching the tip of the dropper to the sclera of the eye.
Correct Answer: A
Rationale: The correct answer is A: Administer the medications 5 minutes apart. Timolol and pilocarpine are both used to treat glaucoma but work differently. Timolol is a beta-blocker that reduces intraocular pressure while pilocarpine constricts the pupil to improve drainage. Administering them 5 minutes apart prevents one medication from washing out the other. Choice B is incorrect as pressure on the conjunctival sac is not necessary. Choice C is incorrect as contact lenses should be removed before administering eye drops. Choice D is incorrect as touching the dropper tip to the eye can lead to infections.
A nurse is preparing a client who is to receive chemotherapy for treatment of ovarian cancer. Which of the following actions should the nurse plan to take?
- A. Tell the client to expect dark stools following chemotherapy.
- B. Have the client swish with commercial mouthwash before therapy.
- C. Administer an antiemetic prior to the procedure.
- D. Have the client floss 4 times daily.
Correct Answer: C
Rationale: The correct answer is C: Administer an antiemetic prior to the procedure. This is important because chemotherapy often causes nausea and vomiting. Administering an antiemetic helps prevent or reduce these side effects, promoting client comfort and compliance with treatment. Choice A is incorrect because dark stools are not a common side effect of chemotherapy for ovarian cancer. Choice B is incorrect as using mouthwash before therapy may not be relevant to chemotherapy administration. Choice D is incorrect as flossing frequency is not directly related to chemotherapy treatment.
A nurse is assessing a client who has hyperthyroidism. The nurse should expect the client to report which of the following manifestations?
- A. Constipation
- B. Sensitivity to cold
- C. Weight gain of 4.5 kg (10 lbs) in 3 weeks
- D. Frequent mood changes
Correct Answer: D
Rationale: The correct answer is D: Frequent mood changes. In hyperthyroidism, there is an excessive production of thyroid hormones leading to symptoms such as irritability, anxiety, and mood swings. This is due to the increased metabolic activity caused by the excess thyroid hormones. Constipation (A) is more common in hypothyroidism. Sensitivity to cold (B) is also seen in hypothyroidism due to decreased metabolic rate. Weight gain of 4.5 kg (10 lbs) in 3 weeks (C) is unlikely in hyperthyroidism as it usually leads to weight loss. Therefore, choice D is the most appropriate manifestation for hyperthyroidism.