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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. Advise 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 indicates hyperkalemia, which can lead to serious cardiac arrhythmias. Therefore, obtaining an ECG is crucial to assess for any potential cardiac abnormalities. Choice B is incorrect as salt substitutes often contain potassium, exacerbating the issue. Choice C is incorrect as citrus juices and bananas are high in potassium, which should be avoided in hyperkalemia. Choice D is incorrect as it focuses on sodium levels, not addressing the immediate concern of hyperkalemia.
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A nurse is providing care for a client who is 2 days postoperative following abdominal surgery and is about to progress from a clear liquid diet to full liquids. Which of the following items should the nurse tell the client he may now request to have on his meal tray?
- A. Chicken broth
- B. Flavored gelatin
- C. Cranberry juice
- D. Skim milk
Correct Answer: D
Rationale: The correct answer is D: Skim milk. Skim milk is allowed on a full liquid diet as it is easily digested and provides essential nutrients. It is also a good source of protein and calcium, important for healing post-surgery. Chicken broth (A) and flavored gelatin (B) are typically allowed on a clear liquid diet but may not be suitable for a full liquid diet. Cranberry juice (C) is acidic and may be too harsh on the stomach post-surgery. Therefore, the nurse should advise the client to choose skim milk for his meal tray to support healing and recovery.
A nurse is preparing a client who is postoperative following a below-the-knee amputation for a leg prosthesis fitting. Which of the following actions should the nurse take?
- A. Wrap the stump with an elastic bandage in a figure-eight configuration.
- B. Remove the elastic bandage and re-wrap the stump once per day.
- C. Perform passive range of motion exercises once daily.
- D. Secure the elastic bandage to the lowest joint.
Correct Answer: A
Rationale: The correct answer is A: Wrap the stump with an elastic bandage in a figure-eight configuration. This action helps reduce swelling, provide support, and shape the stump for prosthesis fitting. Wrapping in a figure-eight pattern ensures even compression and prevents constriction. Choice B is incorrect as frequent re-wrapping can disrupt wound healing. Choice C is unnecessary and may cause discomfort. Choice D is incorrect as securing the bandage at the lowest joint can lead to constriction and hinder circulation.
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 caring for a client who has acute respiratory distress syndrome (ARDS) and requires mechanical ventilation. The client receives a prescription for pancuronium. The nurse recognizes that this medication is for which of the following purposes?
- A. Induce sedation.
- B. Suppress respiratory effort.
- C. Decrease chest wall compliance.
- D. Decrease respiratory secretions.
Correct Answer: B
Rationale: The correct answer is B: Suppress respiratory effort. Pancuronium is a neuromuscular blocking agent that paralyzes skeletal muscles, including the muscles involved in breathing. In ARDS, the client may have difficulty breathing due to lung damage, so pancuronium can be used to facilitate mechanical ventilation by preventing respiratory muscle movement. This allows the ventilator to control the client's breathing without interference. The other choices are incorrect because pancuronium does not induce sedation (A), affect chest wall compliance (C), or decrease respiratory secretions (D). It solely works to suppress respiratory effort by blocking neuromuscular transmission.
A nurse is preparing to administer fluoxetine 30 mg PO daily to a client. The amount available is fluoxetine 10 mg tablets. How many tablets should the nurse administer per dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero)
Correct Answer: 3
Rationale: The correct answer is 3 tablets. To achieve a total of 30 mg, the nurse should administer 3 tablets of 10 mg each (10 mg x 3 = 30 mg). Other choices are incorrect because: A) 1 tablet is not enough to reach 30 mg, B) 2 tablets only add up to 20 mg, C) 4 tablets exceed the required dose, D) 5 tablets exceed the required dose, E) 6 tablets exceed the required dose, F) 7 tablets exceed the required dose, G) 8 tablets exceed the required dose.