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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. Hyponatremia
- D. Hyperkalemia
Correct Answer: C
Rationale: Hyponatremia occurs from fluid and sodium loss in vomiting and diarrhea.
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A nurse is assisting with feeding a client who has had a stroke. Which of the following findings should the nurse identify as a manifestation of dysphagia?
- A. Rapid chewing
- B. Garbled voice
- C. Sneezing
- D. Increased hunger
Correct Answer: B
Rationale: A garbled voice post-stroke indicates swallowing difficulty, a dysphagia sign.
A nurse is coordinating care of a group of clients with an assistive personnel (AP). Which of the following tasks should the nurse assign to the AP?
- A. Assess the pain level of a client who has received acetaminophen.
- B. Measure the intake and output of a client who has received furosemide.
- C. Check a client's peripheral IV site for redness or swelling.
- D. Reinforce teaching with a client about crutch-gait walking.
Correct Answer: B
Rationale: Measuring intake and output is within the AP's scope; assessment and teaching are nurse responsibilities.
A nurse is caring for a client who has a terminal illness. The client asks what type of care will be provided as death approaches. Which of the following statements should the nurse make first?
- A. We can talk to the provider about incorporating nonpharmacological pain management in your care.
- B. Tell me your expectations about activities related to the end-of-life.
- C. You can allow your family to visit as often as you wish.
- D. You can provide the name of a spiritual support person we can contact for you.
Correct Answer: B
Rationale: Exploring the client's expectations first ensures care aligns with their wishes.
A nurse is preparing to administer medications to a client. Which of the following pieces of information should the nurse use as a client identifier?
- A. Room number
- B. Medical diagnosis
- C. Photograph
- D. Age
Correct Answer: C
Rationale: A photograph is a reliable identifier per safety standards, unlike room number or age.
A nurse is observing an assistive personnel (AP) provide postmortem care for a client prior to visitation by their loved ones. Which of the following actions by the AP requires intervention by the nurse?
- A. Washing the client's face
- B. Gathering the client's personal belongings
- C. Removing the client's dentures from their mouth
- D. Closing the client's eyes
Correct Answer: C
Rationale: Removing dentures alters appearance unnaturally; they should remain unless otherwise specified.