Nokea
A nurse receives a client's laboratory results and notes a potassium level of 3.1 mEq/L. When reviewing the client's medication administration record, which of the following types of medication should the nurse identify as a contributing factor to the client's electrolyte imbalance?
- A. Corticosteroids
- B. NSAIDs
- C. ACE inhibitors
- D. SSRIs
Correct Answer: A
Rationale: Corticosteroids can cause potassium loss through increased renal excretion, leading to hypokalemia.
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A nurse at a community health clinic is assisting with creating a brochure about testicular cancer. Which of the following information should the nurse include?
- A. Perform a testicular self-examination twice per year.
- B. Palpate the epididymis.
- C. Gently roll the testicles to feel for abnormalities.
- D. Use one hand to palpate the testicles.
Correct Answer: C
Rationale: The correct answer is C: Gently roll the testicles to feel for abnormalities. This is the most appropriate information to include in the brochure because gently rolling the testicles between the thumb and fingers is the recommended technique for testicular self-examination. By rolling the testicles, individuals can better detect any lumps or changes in texture that may indicate testicular cancer.
Choice A is incorrect because the current recommendation is to perform testicular self-exams monthly, not twice per year. Choice B is incorrect as palpating the epididymis is not part of the standard testicular self-examination procedure. Choice D is incorrect because using both hands is recommended for better examination.
A nurse is contributing to the plan of care for a client who is a Seventh-Day Adventist. To provide spiritually and culturally sensitive care, which of the following interventions should the nurse suggest for this client?
- A. Do not schedule diagnostic tests for Saturday.
- B. Arrange for him to receive the sacrament of the sick.
- C. Assign same-gender caregivers.
- D. Offer him a kosher dietary menu.
Correct Answer: A
Rationale: The correct answer is A: Do not schedule diagnostic tests for Saturday. Seventh-Day Adventists observe Saturday as a holy day of rest and worship, known as the Sabbath. By avoiding scheduling diagnostic tests on Saturdays, the nurse respects the client's religious beliefs and practices. This intervention promotes culturally sensitive care by acknowledging and accommodating the client's spiritual needs.
Choice B (Arrange for him to receive the sacrament of the sick) is incorrect as this intervention is specific to the Catholic faith, not Seventh-Day Adventist beliefs. Choice C (Assign same-gender caregivers) is not directly related to the client's religious preferences and may not be necessary for providing culturally sensitive care in this context. Choice D (Offer him a kosher dietary menu) is more aligned with Jewish dietary laws, which do not specifically apply to Seventh-Day Adventist beliefs.
A nurse in a dialysis center is caring for a client who has a new diagnosis of end-stage renal disease. At the first dialysis treatment, the client tells the nurse, 'I decided to come today, but I am not sure if I will need to come back again this week. I am feeling much better since my discharge from the hospital and I think my kidneys are working again.' The nurse should recognize the client is demonstrating which stage of Kübler-Ross's stages of grieving?
- A. Bargaining
- B. Denial
- C. Depression
- D. Anger
Correct Answer: B
Rationale: The correct answer is B: Denial. The client's statement indicates denial as they are refusing to accept the reality of their condition and are hopeful that their kidneys are functioning again, despite the need for dialysis. This stage in Kübler-Ross's stages of grieving involves avoiding the truth to cope with the overwhelming emotions. Bargaining (A), Depression (C), and Anger (D) are not demonstrated in the client's statement. Bargaining involves seeking alternatives to the situation, Depression involves feelings of sadness and hopelessness, and Anger involves frustration and resentment.
A nurse is assisting with the admission of a client who is hyperventilating, reports lightheadedness and paresthesias, and has blurred vision and a new onset of confusion. The nurse should suspect that the client has developed which of the following imbalances?
- A. Metabolic acidosis
- B. Metabolic alkalosis
- C. Respiratory acidosis
- D. Respiratory alkalosis
Correct Answer: D
Rationale: The correct answer is D, respiratory alkalosis. Hyperventilation causes excessive loss of carbon dioxide, leading to respiratory alkalosis. This is evidenced by lightheadedness, paresthesias, blurred vision, and confusion due to decreased carbon dioxide levels in the blood. Metabolic acidosis (A) is characterized by low pH and bicarbonate levels, not seen in this scenario. Metabolic alkalosis (B) is due to excess bicarbonate, which is not present in hyperventilation. Respiratory acidosis (C) is caused by retention of carbon dioxide, opposite of what is seen in hyperventilation.
A nurse is reinforcing teaching with a client who has atelectasis. The nurse tells the client how to position herself to promote drainage of the apical lung segments. Which of the following statements by the client should the nurse identify as understanding of the teaching?
- A. I will sit up on the side of the bed with my legs dangling.
- B. I will turn on my left side with my legs elevated higher than my chest.
- C. I will position myself on my back with my head lower than my feet.
- D. I will lie on my abdomen with pillows under my stomach and chest.
Correct Answer: D
Rationale: Prone positioning with pillows under the chest promotes postural drainage of apical lung segments. Other positions are ineffective.