Nokea
A nurse is preparing to administer potassium chloride (KCL) to a client who is receiving diuretic therapy. The nurse reviews the client's serum potassium level results and discovers the client's potassium level is 3.2 mEq/L. Which of the following actions should the nurse take?
- A. Give the ordered KCL as prescribed.
- B. Hold the KCL and notify the healthcare provider.
- C. Administer potassium via IV push.
- D. Check the client's potassium level again in 1 hour.
Correct Answer: A
Rationale: The correct answer is A: Give the ordered KCL as prescribed. The nurse should administer potassium chloride as prescribed because the client's potassium level of 3.2 mEq/L is within the normal range (3.5-5.0 mEq/L). Potassium chloride is indicated for clients with hypokalemia (low potassium levels), and the client's level falls within the normal range, so administering the ordered KCL is appropriate. Holding the KCL is unnecessary since the potassium level is not critically low. Administering potassium via IV push is not indicated as the client's potassium level is not critically low. Checking the client's potassium level again in 1 hour is unnecessary as the level is already within the normal range.
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While assessing a client who is receiving continuous IV therapy via his left forearm, a nurse notes that the site is red, swollen, and painful and that the surrounding tissues are hard. Which of the following actions should the nurse take first?
- A. Discontinue the existing IV line
- B. Apply warm compresses
- C. Elevate the extremity
- D. Notify the healthcare provider
Correct Answer: A
Rationale: The correct action is to discontinue the existing IV line first. This is crucial because the client is exhibiting signs of infiltration, which can lead to tissue damage and complications. By removing the IV line, further damage can be prevented. Applying warm compresses or elevating the extremity may not address the underlying issue and could potentially worsen the condition. Notifying the healthcare provider is important but should not be the first step in this situation.
A nurse is teaching self-management to a client who has hepatitis B. Which of the following instructions should the nurse include in the teaching?
- A. Rest frequently throughout the day.
- B. Increase physical activity gradually.
- C. Take medication with meals.
- D. Drink fluids to stay hydrated.
Correct Answer: A
Rationale: The correct answer is A: Rest frequently throughout the day. This is important for a client with hepatitis B to allow the body to heal and conserve energy. Choice B may be harmful as excessive physical activity can strain the liver. Choice C is incorrect as medication for hepatitis B is usually taken on an empty stomach. Choice D is important but not specific to hepatitis B management.
A nurse is teaching a class about preventive care to clients who are at risk for acquiring viral hepatitis. Which of the following information should the nurse include in the presentation?
- A. Avoid foods prepared with tap water.
- B. Vaccination against hepatitis B and C is recommended.
- C. Wash hands thoroughly after using the restroom.
- D. Food should be prepared with purified water.
Correct Answer: D
Rationale: The correct answer is D: Food should be prepared with purified water. Hepatitis A virus can be spread through contaminated water or food. Using purified water for food preparation can help prevent the transmission of the virus. Choice A is incorrect because avoiding foods prepared with tap water alone may not be sufficient to prevent hepatitis. Choice B is incorrect as there is no vaccination available for hepatitis C. Choice C is important for general hygiene but may not specifically prevent hepatitis transmission.
A nurse explains to a client why two chest tubes are in place after a lobectomy. What is the lower chest tube for?
- A. Draining air from the pleural space
- B. Draining blood and fluid from the pleural space
- C. Providing oxygen directly to the lungs
- D. Preventing lung collapse
Correct Answer: B
Rationale: The lower chest tube after a lobectomy is to drain blood and fluid from the pleural space. This is crucial to prevent complications such as fluid accumulation, which can lead to infection or impaired lung expansion. The other choices are incorrect because: A) Draining air is usually done by the upper chest tube, C) Providing oxygen does not require a chest tube, and D) Preventing lung collapse is more related to the function of the upper chest tube in maintaining negative pressure in the pleural space.
A nurse is caring for a client who the provider suspects might have pernicious anemia. The nurse should expect the provider to prescribe which of the following diagnostic tests?
- A. Schilling test
- B. Complete blood count (CBC)
- C. Vitamin B12 level
- D. Bone marrow biopsy
Correct Answer: A
Rationale: The correct answer is A: Schilling test. Pernicious anemia is caused by vitamin B12 deficiency, often due to poor absorption. The Schilling test is specifically used to diagnose pernicious anemia by evaluating the body's ability to absorb vitamin B12. The test involves giving the patient a small amount of radioactive vitamin B12 to determine how well it is absorbed and utilized by the body. This test helps to differentiate pernicious anemia from other causes of B12 deficiency.
Choice B (Complete blood count) is a general test that may show abnormalities in red blood cells seen in anemia, but it does not specifically diagnose pernicious anemia. Choice C (Vitamin B12 level) alone may not differentiate between pernicious anemia and other causes of B12 deficiency. Choice D (Bone marrow biopsy) is not typically necessary for diagnosing pernicious anemia and is more invasive compared to the Schilling test.