Nokea
A nurse is reviewing the laboratory results for a client who reports vomiting and diarrhea for 2 days. Which of the following laboratory findings should the nurse expect?
- A. Hyperkalemia
- B. Hypocalcemia
- C. Hyponatremia
- D. Hypermagnesemia
Correct Answer: C
Rationale: Vomiting and diarrhea cause sodium loss, leading to hyponatremia.
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A nurse in a provider's office is collecting data from an older adult client. The client states that he is having difficulty sleeping. Which of the following strategies should the nurse recommend to promote sleep?
- A. Drink a glass of milk before bedtime.
- B. Watch television in bed.
- C. Take a long walk before bedtime.
- D. Take a 1-hour nap each day.
Correct Answer: A
Rationale: Milk contains tryptophan, which promotes sleepiness.
A nurse is caring for an adult client who has a developmental disability. The client requires an emergency appendectomy, and the staff cannot reach the appointed guardian. Which of the following is an appropriate action for the nurse to take?
- A. Postpone the procedure until the staff contacts the guardian.
- B. Obtain consent from the client.
- C. Request that the provider sign the consent form.
- D. Prepare the client for surgery with implied consent.
Correct Answer: D
Rationale: In emergencies, implied consent allows life-saving procedures when delaying could harm the client.
A nurse is preparing to administer ampicillin to a school-age child who weighs 55 lb. The provider prescribes 50 mg/kg/day in 4 equal doses. Available is ampicillin oral suspension 125 mg/5 mL. How many mL should the nurse administer with each dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer: 12.5 mL
Rationale: 55 lb = 25 kg; 50 mg/kg/day = 1250 mg/day; 1250 mg / 4 doses = 312.5 mg/dose; 312.5 mg / (125 mg/5 mL) = 12.5 mL/dose.
A nurse is preparing to instill an otic medication for an adult client. Which of the following actions should the nurse take?
- A. Request the client remain supine for 10 min following administration.
- B. Pull the client's pinna downward and back.
- C. Hold the ear dropper 1 cm (0.5 in) from the client's ear.
- D. Cleanse the client's outer ear with isopropyl alcohol to remove wax.
Correct Answer: C
Rationale: Holding the dropper 1 cm from the ear ensures precise administration without contamination.
The client is at risk for developing ___ as evidenced by the client's ___
- A. Infection
- B. WBC count
Correct Answer: A,B
Rationale: A: Chemotherapy lowers immunity, increasing infection risk. B: Decreased WBC count (4,000/mm³) indicates leukopenia.