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. Hypocalcemia
- B. Hypermagnesemia
- C. Hyperkalemia
- D. Hypokalemia
Correct Answer: D
Rationale: Vomiting and diarrhea cause potassium loss, leading to hypokalemia.
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A nurse is reinforcing teaching about advance directives with a client who has terminal colorectal cancer. Which of the following statements by the client indicates an understanding of the teaching?
- A. I'm glad to have the opportunity to choose what kind of care I receive while I still can.
- B. If I want life support, I'll need to sign a separate consent form first.
- C. I can't change my mind about the care I will receive once I sign my living will.
- D. Once I fill out my living will, there will be a 1-month delay before it is legally binding.
Correct Answer: A
Rationale: Advance directives allow clients to specify care preferences, reflecting autonomy.
A nurse is caring for a client who requires a sterile dressing change. The nurse should recognize that the surgical field has been contaminated if which of the following actions occur?
- A. A pair of sterile forceps is allowed to rest in a container of sterile water on the field.
- B. The sterile solution is poured with the bottle held over the field.
- C. Unnecessary sterile items are placed on the field.
- D. The handle of a pair of sterile scissors is resting 5 cm (2 in) from the field's edge.
Correct Answer: B
Rationale: Pouring over the field risks contamination from the bottle.
A nurse is setting up a sterile field in a client's room. Which of the following actions should the nurse take?
- A. Placing a sterile instrument within 1.3 cm (0.5 in) of the edge of the sterile field
- B. Opening the top flap of the sterile tray package away from their body
- C. Dropping sterile objects onto the field from a height of 5 cm (2 in)
- D. Placing the cap of a sterile solution on a clean surface with the inside facing down
Correct Answer: B
Rationale: Opening the flap away maintains sterility by keeping the nurse's body out of the field.
A nurse is reviewing a client's electronic medical record (EMR). Which of the findings should the nurse identify as a risk factor for a potential accident or injury?
- A. History of dementia
- B. Steady gait
- C. History of gastric reflux
- D. Age of 45
Correct Answer: A
Rationale: Dementia increases confusion and fall risk, predisposing to accidents.
A nurse at a long-term care facility is reinforcing teaching with a newly licensed nurse about the proper use of restraints. Which of the following instructions should the nurse include in the teaching? (Select all that apply.)
- A. Observe the client's skin integrity every 2 hr.
- B. Use a square knot to secure the client's restraint to the bed.
- C. Ensure that 2 fingers can be placed between the restraint and the client.
- D. Tie the ends of the restraint to the client's bed rail.
- E. Pad bony prominences before applying a restraint.
Correct Answer: A,C,E
Rationale: A: Frequent skin checks prevent injury. C: Two fingers ensure proper fit. E: Padding protects bony areas.