Nokea
A nurse is reviewing the EKG strip of a client who has prolonged vomiting. Which of the following abnormalities on the client's EKG should the nurse interpret as a sign of hypokalemia?
- A. Abnormally prominent U wave
- B. Tachycardia
- C. Flattened P wave
- D. Prolonged PR interval
Correct Answer: A
Rationale: The correct answer is A: Abnormally prominent U wave. In hypokalemia, low potassium levels can lead to U wave prominence on an EKG. The U wave becomes more visible and prominent due to delayed repolarization of the Purkinje fibers. This is a classic EKG finding in hypokalemia. Tachycardia (choice B) is a non-specific finding and can be caused by various conditions. Flattened P wave (choice C) is seen in hyperkalemia, not hypokalemia. Prolonged PR interval (choice D) is more indicative of first-degree heart block or other conduction abnormalities, not specifically hypokalemia.
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A nurse is preparing a client for radiation after a mastectomy. What adverse effect should be expected?
- A. Alopecia
- B. Diarrhea
- C. Fatigue
- D. Weight gain
Correct Answer: C
Rationale: The correct answer is C: Fatigue. Radiation therapy often causes fatigue due to its impact on healthy cells surrounding the treatment area. This can result in decreased energy levels and overall tiredness. Alopecia (A) is more commonly associated with chemotherapy. Diarrhea (B) is a potential side effect of certain chemotherapy drugs or radiation to the abdominal area. Weight gain (D) is not a typical adverse effect of radiation therapy.
A nurse at a rehabilitation center is planning care for a client who had a left hemispheric cerebrovascular accident (CVA) 3 weeks ago. Which of the following goals should the nurse include in the client's rehabilitation program?
- A. Establish the ability to communicate effectively.
- B. Increase mobility on the affected side.
- C. Increase independence in activities of daily living.
- D. Prevent falls during rehabilitation.
Correct Answer: A
Rationale: The correct answer is A: Establish the ability to communicate effectively. Communication is a key aspect affected by left hemispheric CVA, which can lead to aphasia or difficulty in speaking and understanding language. By prioritizing communication goals, the nurse can enhance the client's quality of life, facilitate social interactions, and improve overall rehabilitation outcomes. Increasing mobility (B) and independence in activities of daily living (C) are important but may not directly address the communication deficits. Preventing falls (D) is also crucial but not specific to the client's primary deficit.
A nurse is planning an educational program about basal cell carcinoma. Which of the following information should the nurse plan to include?
- A. Basal cell carcinoma has a low incidence of metastasis.
- B. Basal cell carcinoma is often fatal.
- C. Basal cell carcinoma metastasizes early.
- D. Basal cell carcinoma is more common in younger clients.
Correct Answer: A
Rationale: The correct answer is A: Basal cell carcinoma has a low incidence of metastasis. Basal cell carcinoma rarely metastasizes to other parts of the body, making it highly curable through surgical excision. This information is crucial for patients to understand the low likelihood of the cancer spreading. Choices B and C are incorrect because basal cell carcinoma is not typically fatal nor does it metastasize early. Choice D is incorrect as basal cell carcinoma is more common in older adults, not younger clients.
A nurse is caring for a client who has HIV. Which of the following laboratory values is the nurse's priority?
- A. CD4-T-cell count 180 cells/mm3
- B. White blood cell count 10,000/mm3
- C. Hemoglobin 12.5 g/dL
- D. Platelet count 200,000/mm3
Correct Answer: A
Rationale: The correct answer is A: CD4-T-cell count 180 cells/mm3. In HIV, monitoring CD4-T-cell count is crucial as it reflects the immune system's ability to fight infections. A low CD4 count indicates immunosuppression, increasing the risk of opportunistic infections. Therefore, it is the nurse's priority to monitor and ensure the CD4 count remains above critical levels to prevent complications.
Other choices are incorrect because:
B: White blood cell count is important but not as specific to HIV management.
C: Hemoglobin level is important for assessing anemia but not a priority in HIV care.
D: Platelet count is important for clotting but not directly related to HIV progression.
A nurse is providing dietary teaching to a client who has a history of recurring calcium oxalate kidney stones. Which of the following instructions should the nurse include in the teaching?
- A. Increase calcium intake
- B. Avoid foods high in potassium
- C. Drink 3 L of fluid every day
- D. Limit vitamin C intake
Correct Answer: C
Rationale: The correct answer is C: Drink 3 L of fluid every day. Adequate fluid intake helps to dilute urine, reducing the concentration of calcium and oxalate, which are the main components of kidney stones. This instruction can help prevent the formation of new stones. Increasing calcium intake (Choice A) may actually be beneficial as it can bind with oxalate in the intestines, reducing its absorption and subsequent excretion in the urine. Avoiding foods high in potassium (Choice B) is not directly related to preventing calcium oxalate stones. Limiting vitamin C intake (Choice D) is not necessary unless the client is taking excessive amounts of vitamin C supplements, which can increase oxalate levels.