Nokea
A nurse is phoning a provider to report a client's serum potassium of 6.2 mEq/L. Which of the following medications should the nurse expect the provider to prescribe?
- A. Potassium iodide.
- B. Lactulose.
- C. Sodium polystyrene sulfonate.
- D. Acetylcysteine.
Correct Answer: C
Rationale: Sodium polystyrene sulfonate is used to treat hyperkalemia by exchanging sodium ions for potassium ions in the intestines, lowering serum potassium levels.
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A nurse is reinforcing teaching with a client who is to self-administer regular insulin and NPH insulin from the same syringe. Which of the following instructions should the nurse provide?
- A. Discard regular insulin if it appears cloudy.
- B. Draw up the NPH insulin into the syringe first.
- C. Shake the NPH insulin until it is well-mixed.
- D. Inject air into the regular insulin first.
Correct Answer: A
Rationale: Regular insulin should be clear; if it appears cloudy, it may be contaminated or expired and should be discarded to ensure safe administration.
A nurse is reviewing the laboratory results of a client who is postoperative and has a respiratory rate of 7/min. The arterial blood gas (ABG) values include: pH 7.22, PaCO₂ 68 mm Hg, Base excess -2, PaO₂ 78 mm Hg, Oxygen saturation 80%, Bicarbonate 28 mEq/L. Which of the following interpretations of the ABG values should the nurse make?
- A. Respiratory alkalosis.
- B. Respiratory acidosis.
- C. Metabolic acidosis.
- D. Metabolic alkalosis.
Correct Answer: B
Rationale: Low pH (7.22) and high PaCO₂ (68 mm Hg) indicate respiratory acidosis, caused by CO₂ accumulation due to inadequate ventilation.
A nurse is collecting data on a client who is postoperative following a transurethral resection of the prostate (TURP). The nurse should recognize which of the following findings is the priority?
- A. The client has small blood clots in his urinary catheter.
- B. The client reports a continuous urge to void.
- C. The client reports burning around the urinary catheter.
- D. The client has bright red urine in his urinary catheter.
Correct Answer: D
Rationale: Bright red urine indicates active bleeding, a serious complication requiring immediate attention to prevent hemorrhage.
A nurse is reinforcing discharge teaching with a client who has osteoarthritis. Which of the following statements by the client indicates an understanding of the teaching?
- A. Osteoarthritis is caused by inflammation that affects both joints and other body tissues.
- B. Osteoarthritis occurs due to the aging process and results in disintegration of cartilage in a joint.
- C. Osteoarthritis is due to loss of calcium in the bones, which can lead to increased risk for bone fractures.
- D. Osteoarthritis happens in several phases when deposits of crystals develop in joints and soft tissues.
Correct Answer: B
Rationale: Osteoarthritis is a degenerative joint disease caused by aging and cartilage disintegration, as correctly stated.
A nurse is assisting with the care of a client immediately following a lumbar puncture. Which of the following actions should the nurse take? (Select all that apply.)
- A. Monitor the puncture site for hematoma.
- B. Elevate the client's head of bed.
- C. Insert a urinary catheter.
- D. Encourage fluid intake.
- E. Apply a cervical collar to the client.
Correct Answer: A,D
Rationale: Monitoring the puncture site for hematoma and encouraging fluid intake are crucial to detect complications and replenish cerebrospinal fluid, reducing the risk of post-lumbar puncture headache.