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A nurse is caring for four clients who have drainage tubes. Which of the following clients should the nurse recognize as being at risk for hypokalemia?
- A. The client who has a nasogastric (NG) tube to suction
- B. The client who has a chest tube to water seal
- C. The client who has an indwelling urinary catheter to gravity drainage
- D. The client who has a tracheostomy tube attached to humidified oxygen
Correct Answer: A
Rationale: The correct answer is A: The client who has a nasogastric (NG) tube to suction. Suctioning through the NG tube can lead to loss of gastric contents, including potassium, which can result in hypokalemia. The other choices do not directly affect potassium levels. B: A chest tube to water seal is used to drain air or fluid from the pleural space, not likely to cause hypokalemia. C: An indwelling urinary catheter to gravity drainage does not impact potassium levels. D: A tracheostomy tube with humidified oxygen does not affect potassium levels. Therefore, the client with the NG tube to suction is at risk for hypokalemia due to potential potassium loss.
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A nurse is teaching a class about expected physiological changes in older adult clients. Which of the following changes should the nurse include?
- A. Increase in startle reflex
- B. Increase in muscle mass
- C. Decrease in body fat
- D. Decrease in systolic blood pressure
Correct Answer: A
Rationale: The correct answer is A: Increase in startle reflex. As individuals age, their neurological system undergoes changes leading to increased sensitivity and exaggerated responses, including an increase in the startle reflex. This change is attributed to alterations in neurotransmitter levels and sensory processing.
Incorrect Answers:
B: Increase in muscle mass - Muscle mass typically decreases with age due to hormonal changes and decreased physical activity.
C: Decrease in body fat - Older adults tend to experience an increase in body fat and a decrease in muscle mass, contributing to changes in body composition.
D: Decrease in systolic blood pressure - While blood pressure tends to increase with age due to changes in blood vessel elasticity and hormonal changes, a decrease in systolic blood pressure is not a common expected physiological change in older adults.
A nurse is preparing to administer a client's antihypertensive medication. When using clinical judgment, which of the following findings indicates the nurse should further assess the client before administering medication?
- A. The client reports dizziness when ambulating to the bathroom
- B. The client reports having trouble sleeping the previous night
- C. The client ate 60% of their breakfast
- D. The client has a urine output of 400 mL for the past 8 hr
Correct Answer: A
Rationale: The correct answer is A. Dizziness when ambulating can be a sign of orthostatic hypotension, a potential side effect of antihypertensive medication. The nurse should further assess for signs of hypotension before administering the medication. Choices B, C, and D are less relevant to antihypertensive medication administration. Reporting trouble sleeping, eating 60% of breakfast, and having a urine output of 400 mL are not direct contraindications for administering antihypertensive medication.
A nurse is preparing to perform hand hygiene with an alcohol-based hand sanitizer. Which of the following actions should the nurse plan to take?
- A. Use hot water to rinse hand sanitizer off
- B. Dry hands with a reusable towel
- C. Rub hands together 20 seconds
- D. Rub hand sanitizer around rings on fingers
Correct Answer: D
Rationale: The correct answer is D: Rub hand sanitizer around rings on fingers. This is important because rings can harbor bacteria and viruses, and by rubbing hand sanitizer around them, the nurse ensures that all surfaces of the hands, including under the rings, are effectively sanitized. This action helps prevent the transmission of pathogens.
A: Using hot water to rinse hand sanitizer off is unnecessary and can actually be harmful as it can cause skin irritation.
B: Drying hands with a reusable towel is not recommended as it can harbor germs and compromise hand hygiene.
C: Rubbing hands together for 20 seconds is a good practice, but the specific action related to rings is more crucial.
E, F, G: No information provided.
A nurse in an emergency department is performing triage on a group of clients. Which of the following clients should the nurse see first?
- A. A client who has heart failure and peripheral edema
- B. A client who reports urinary burning and a temperature of 29.2° C (102.51 F)
- C. A client who has cirrhosis of the liver and bruising on their arms
- D. A client who has a new onset of atrial fibrillation and a heart rate of 152/min
Correct Answer: D
Rationale: The correct answer is D because a new onset of atrial fibrillation with a heart rate of 152/min indicates a potentially life-threatening cardiac condition requiring immediate attention to prevent complications such as stroke or heart failure. Atrial fibrillation can lead to decreased cardiac output and increase the risk of blood clots forming in the heart. The high heart rate can also lead to hemodynamic instability. A prompt assessment and intervention are crucial to stabilize the client's condition.
Choice A is incorrect as heart failure with peripheral edema, while concerning, does not pose an immediate life-threatening risk compared to a new onset of atrial fibrillation.
Choice B is incorrect as urinary burning and a temperature of 29.2° C (102.51 F) may indicate a urinary tract infection, which is important but not as urgent as the cardiac issue in choice D.
Choice C is incorrect as bruising in a client with cirrhosis of the liver is concerning for potential bleeding disorders, but it is not
A nurse is teaching a client how to use crutches. Which of the following interventions uses the psychomotor domain of learning?
- A. Describe the steps of walking with crutches for the client
- B. Encourage the client to ask questions about walking with crutches
- C. Show the client a video on walking with crutches
- D. Ask the client to demonstrate walking with crutches
Correct Answer: D
Rationale: The correct answer is D: Ask the client to demonstrate walking with crutches. This intervention engages the psychomotor domain of learning by requiring the client to physically demonstrate the skill being taught. This hands-on approach helps the client develop muscle memory and coordination needed to effectively use crutches.
A, B, and C do not directly involve physical action or demonstration by the client. A describes verbal instruction, B encourages questioning and discussion, and C involves visual learning through a video. While these interventions are valuable in the learning process, they do not specifically target the physical practice of using crutches.
In summary, option D is the correct choice as it actively engages the client in practicing the skill, aligning with the psychomotor domain of learning.