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A nurse on a medical unit is reviewing the laboratory reports for a client. Which of the following laboratory values is the priority to report to the provider?
- A. Potassium level 3 mEq/L
- B. BUN 9.5 mg/dL
- C. Creatinine 0.4 mg/dL
- D. Sodium 135 mEq/L
Correct Answer: A
Rationale: The correct answer is A: Potassium level 3 mEq/L. A potassium level of 3 mEq/L is below the normal range (3.5-5.0 mEq/L), indicating hypokalemia. Hypokalemia can lead to serious cardiac arrhythmias. Therefore, it is crucial to report this abnormal potassium level promptly to the provider for further evaluation and intervention.
B: BUN 9.5 mg/dL - This is within the normal range (7-20 mg/dL) and does not require immediate intervention.
C: Creatinine 0.4 mg/dL - This is within the normal range (0.6-1.2 mg/dL) and does not indicate an urgent issue.
D: Sodium 135 mEq/L - This is within the normal range (135-145 mEq/L) and does not require immediate action.
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A nurse is caring for a client with a scheduled procedure. While preparing the client for transport they appear anxious and ask the nurse where they should hide their cellphone during the procedure. The nurse offers to lock the item in a secure area. Which category of Maslow's hierarchy of needs is the nurse addressing?
- A. Safety needs
- B. Esteem needs
- C. Love and belonging needs
- D. Physiological needs
Correct Answer: A
Rationale: The correct answer is A: Safety needs. At this moment, the nurse is addressing the client's need for safety by offering to secure their cellphone. Safety needs in Maslow's hierarchy refer to feeling secure, stable, and protected. By ensuring the client's belongings are safe, the nurse is addressing this fundamental need, which is crucial for the client's well-being during the procedure. Other choices are incorrect because: B: Esteem needs focus on self-respect and recognition from others, C: Love and belonging needs refer to relationships and social connections, and D: Physiological needs pertain to basic requirements like food and water, none of which are directly addressed in this scenario.
A nurse in an emergency department is performing triage on a group of clients. Which of the following clients should the nurse see first?
- A. A client who has heart failure and peripheral edema
- B. A client who reports urinary burning and a temperature of 29.2° C (102.51 F)
- C. A client who has cirrhosis of the liver and bruising on their arms
- D. A client who has a new onset of atrial fibrillation and a heart rate of 152/min
Correct Answer: D
Rationale: The correct answer is D because a new onset of atrial fibrillation with a heart rate of 152/min indicates a potentially life-threatening cardiac condition requiring immediate attention to prevent complications such as stroke or heart failure. Atrial fibrillation can lead to decreased cardiac output and increase the risk of blood clots forming in the heart. The high heart rate can also lead to hemodynamic instability. A prompt assessment and intervention are crucial to stabilize the client's condition.
Choice A is incorrect as heart failure with peripheral edema, while concerning, does not pose an immediate life-threatening risk compared to a new onset of atrial fibrillation.
Choice B is incorrect as urinary burning and a temperature of 29.2° C (102.51 F) may indicate a urinary tract infection, which is important but not as urgent as the cardiac issue in choice D.
Choice C is incorrect as bruising in a client with cirrhosis of the liver is concerning for potential bleeding disorders, but it is not
A nurse is caring for a client who has a cloudy, opaque area over the lens of one eye. The nurse should identify that this is a manifestation of which of the following visual impairments?
- A. Cataracts
- B. Diabetic retinopathy
- C. Macular degeneration
- D. Glaucoma
Correct Answer: A
Rationale: The correct answer is A: Cataracts. Cataracts cause a cloudy, opaque area over the lens of the eye, leading to blurred vision. This occurs due to the clouding of the lens from protein buildup. Diabetic retinopathy, choice B, involves damage to blood vessels in the retina due to diabetes. Macular degeneration, choice C, affects the central part of the retina leading to distortion or loss of central vision. Glaucoma, choice D, is characterized by increased pressure within the eye damaging the optic nerve. In this scenario, the cloudy, opaque area over the lens specifically points towards cataracts, making it the correct choice.
A nurse is assessing a client for orthostatic hypotension. Which of the following actions should the nurse take first?
- A. Assist the client into a standing position
- B. Check the blood pressure with the client in a supine position
- C. Determine the client's blood pressure 1 min after each position change
- D. Place the client in a sitting position
Correct Answer: B
Rationale: The correct answer is B: Check the blood pressure with the client in a supine position. This is the first action the nurse should take because it establishes the baseline blood pressure of the client in a resting position. Orthostatic hypotension is characterized by a drop in blood pressure upon standing. By measuring the blood pressure in a supine position first, the nurse can accurately assess the extent of the blood pressure change when the client stands up.
Choices A, C, and D are incorrect because they involve positioning changes before establishing the baseline blood pressure. It is crucial to first determine the baseline blood pressure to accurately diagnose orthostatic hypotension. Choice A (Assist the client into a standing position) and D (Place the client in a sitting position) may exacerbate the client's symptoms if orthostatic hypotension is present. Choice C (Determine the client's blood pressure 1 min after each position change) is premature without knowing the baseline blood pressure.
A nurse is teaching a client how to use crutches. Which of the following interventions uses the psychomotor domain of learning?
- A. Describe the steps of walking with crutches for the client
- B. Encourage the client to ask questions about walking with crutches
- C. Show the client a video on walking with crutches
- D. Ask the client to demonstrate walking with crutches
Correct Answer: D
Rationale: The correct answer is D: Ask the client to demonstrate walking with crutches. This intervention engages the psychomotor domain of learning by requiring the client to physically demonstrate the skill being taught. This hands-on approach helps the client develop muscle memory and coordination needed to effectively use crutches.
A, B, and C do not directly involve physical action or demonstration by the client. A describes verbal instruction, B encourages questioning and discussion, and C involves visual learning through a video. While these interventions are valuable in the learning process, they do not specifically target the physical practice of using crutches.
In summary, option D is the correct choice as it actively engages the client in practicing the skill, aligning with the psychomotor domain of learning.