Nokea
A patient with hypokalemia is being monitored. What should the nurse assess for?
- A. Muscle weakness
- B. Flattened T waves
- C. Checking deep tendon reflexes
- D. Seizures
Correct Answer: A
Rationale: Corrected Question: A patient with hypokalemia is being monitored. What should the nurse assess for?
Corrected Choice A: Muscle weakness
Corrected Choice B: Flattened T waves
Corrected Choice C: Checking deep tendon reflexes
Corrected Choice D: Seizures
Rationale: Hypokalemia is associated with muscle weakness due to the effect of low potassium levels on muscle function. Flattened T waves on an ECG are characteristic of hypokalemia but are not a direct assessment for the patient's condition. Checking deep tendon reflexes and seizures are not primary symptoms associated with hypokalemia, making them less relevant for monitoring a patient with this electrolyte imbalance.
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What are the manifestations of osteomyelitis?
- A. Localized pain, swelling, erythema
- B. Elevated white blood cells
- C. Elevated calcium levels
- D. Low potassium levels
Correct Answer: A
Rationale: Osteomyelitis often manifests as localized pain, swelling, and erythema due to infection in the bone. These symptoms are characteristic of inflammation and infection in the bone tissue. Elevated white blood cells (Choice B) may be present as part of the body's immune response to the infection but are not specific manifestations of osteomyelitis. Elevated calcium levels (Choice C) and low potassium levels (Choice D) are not typically associated with osteomyelitis.
A nurse misreads a glucose level and administers insulin for a blood glucose of 210 mg/dL instead of 120 mg/dL. What is the priority intervention?
- A. Monitor for hypoglycemia
- B. Monitor for hyperkalemia
- C. Administer glucose IV
- D. Document the incident
Correct Answer: A
Rationale: The correct answer is to monitor for hypoglycemia. In this scenario, the nurse administered insulin based on a misread glucose level, which could lead to hypoglycemia due to excessive insulin action lowering blood glucose levels. Monitoring for hypoglycemia allows for prompt recognition and intervention if blood glucose levels drop significantly. Choice B, monitoring for hyperkalemia, is incorrect as administering insulin would not cause hyperkalemia. Choice C, administering glucose IV, is not appropriate at this time since the patient's blood glucose level is already elevated. Choice D, documenting the incident, is important but not the priority at this moment when patient safety is at risk due to potential hypoglycemia.
A client has a Transient Ischemic Attack (TIA). What should the nurse teach?
- A. Avoid eating within 3 hours of bedtime
- B. Consume liquids between meals
- C. Eat large meals to increase caloric intake
- D. Avoid liquids to prevent aspiration
Correct Answer: A
Rationale: The correct answer is A: Avoid eating within 3 hours of bedtime. For a client with a Transient Ischemic Attack (TIA), it is crucial to avoid eating within 3 hours of bedtime to reduce reflux that can worsen symptoms. Choice B is incorrect because consuming liquids between meals is not specifically related to managing TIA. Choice C is incorrect as eating large meals may not be recommended, especially if the client needs to watch their caloric intake. Choice D is incorrect because avoiding liquids entirely can lead to dehydration and is not a standard recommendation for TIA management.
What dietary recommendations should be provided to a patient with GERD?
- A. Avoid mint and spicy foods
- B. Eat large meals before bed
- C. Consume liquids with meals
- D. Avoid foods high in potassium
Correct Answer: A
Rationale: The correct recommendation for a patient with GERD is to avoid mint and spicy foods. These types of foods can trigger acid reflux and worsen GERD symptoms. Choice B is incorrect as eating large meals before bed can increase the likelihood of acid reflux due to increased pressure on the lower esophageal sphincter. Choice C is also incorrect as consuming liquids with meals can cause distension in the stomach, potentially leading to reflux. Choice D is not directly related to GERD, as foods high in potassium are generally healthy and not specifically problematic for GERD patients.
A nurse is administering insulin to a patient after misreading their glucose as 210 mg/dL instead of 120 mg/dL. What should the nurse monitor for?
- A. Monitor for hypoglycemia
- B. Monitor for hyperkalemia
- C. Administer glucose IV
- D. Document the incident
Correct Answer: A
Rationale: The correct answer is to monitor for hypoglycemia. Insulin administration based on a misread glucose level can lead to hypoglycemia due to the unnecessary lowering of blood sugar levels. Monitoring for hypoglycemia involves assessing the patient's blood glucose levels frequently, observing for signs and symptoms such as shakiness, confusion, sweating, and administering glucose if hypoglycemia occurs. Choice B, monitoring for hyperkalemia, is incorrect as insulin administration typically lowers potassium levels. Choice C, administering glucose IV, is not the immediate action needed as the patient could potentially develop hypoglycemia from the excess insulin. Choice D, documenting the incident, is important but not the immediate priority when dealing with a potential hypoglycemic event.