Nokea
A nurse is reviewing the laboratory test results from a client who has acute kidney injury (AKI). Which of the following electrolyte imbalances should the nurse expect?
- A. Hypophosphatemia
- B. Hypercalcemia
- C. Hyperkalemia
- D. Hypernatremia
Correct Answer: C
Rationale: Hyperkalemia is expected in AKI due to impaired renal potassium excretion.
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A nurse is caring for a client who has an endotracheal tube and is receiving mechanical ventilation. Which of the following actions should the nurse take to reduce the risk of ventilator-associated pneumonia?
- A. Provide oral care every 4 hours and as needed
- B. Position the head of the client's bed in the flat position
- C. Turn the client every 4 hours
- D. Provide humidity by maintaining moisture within the ventilator tubing
Correct Answer: A
Rationale: Regular oral care reduces bacterial colonization that could lead to VAP.
A nurse is caring for a client who has acute respiratory failure (ARF). The nurse should monitor the client for which of the following manifestations of this condition? (Select all that apply).
- A. Hypoxemia
- B. Confusion
- C. Dyspnea
- D. Bradycardia
- E. Hypocarbia
Correct Answer: A,B,C,E
Rationale: These are common manifestations of ARF reflecting impaired gas exchange and cerebral effects of abnormal blood gases.
A client is admitted to the emergency room with renal calculi. Upon assessment, which of the following findings should the nurse expect?
- A. Bradycardia
- B. Bradypnea
- C. Severe pain
- D. Nocturia
Correct Answer: C
Rationale: Severe pain (renal colic) is the most common symptom of renal calculi, caused by the stone moving and blocking the ureter.
A nurse is caring for a client who reports a new onset of severe chest pain. Which of the following actions should the nurse take to determine if the client is experiencing a myocardial infarction?
- A. Perform a 12-lead ECG
- B. Determine if pain radiates to the left arm
- C. Check the client's blood pressure
- D. Auscultate heart tones
Correct Answer: A
Rationale: ECG is the primary diagnostic tool for MI, showing characteristic ST changes.
A nurse is caring for a client who has heart failure and a prescription for digoxin 125 mcg orally daily. Digoxin is available in 0.25 mg/tablet form. How many tablets should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer: 0.5
Rationale: Calculation: 125 mcg = 0.125 mg; 0.125 mg ÷ 0.25 mg/tablet = 0.5 tablets