Nokea
After initiating a steroid nebulizer treatment for a client with asthma in respiratory distress, which intervention is most important for the nurse to implement?
- A. Monitor pulse oximetry every 2 hours.
- B. Teach proper use of a rescue inhaler.
- C. Elevate the head of bed to 90 degrees.
- D. Determine exposure to asthmatic triggers.
Correct Answer: C
Rationale: Elevating the head of bed to 90 degrees improves breathing and oxygenation by reducing pressure on the diaphragm, increasing lung expansion, and facilitating mucus expectoration.
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The nurse is providing dietary instructions for a client who is being discharged after passing a calcium oxalate renal stone. Which food should the nurse instruct the client to avoid?
- A. Sweet potatoes.
- B. Spinach salad.
- C. Bananas.
- D. Fish.
Correct Answer: B
Rationale: Spinach salad is high in oxalate, which can combine with calcium in the urine to form stones, increasing the risk of recurrence.
The nurse is caring for a client who had an appendectomy 4 hours ago. Which finding requires immediate action by the nurse?
- A. Redness and edema noted at the incision site.
- B. Apical heart rate of 100 to 110 beats/minute.
- C. High-pitched sound heard upon inspiration.
- D. Pain rating of 8 on a scale of 0 to 10.
Correct Answer: C
Rationale: High-pitched sound heard upon inspiration is a sign of stridor, which is a life-threatening emergency that indicates airway obstruction. The nurse should call for help, administer oxygen, and prepare for intubation or tracheostomy.
Following a motor vehicle accident, a client with chest trauma receives a chest tube to relieve a hemothorax. Two hours following the chest tube insertion, the nurse observes the water level in the water-seal chamber is rising during inspiration and falling during expiration. Which action should the nurse implement?
- A. Lift and clear drainage from the chest tube.
- B. Inspect the tube insertion site for leaking.
- C. Continue to monitor the drainage system.
- D. Auscultate lungs for unequal breath sounds.
Correct Answer: C
Rationale: Continuing to monitor the drainage system is the best action for the nurse to implement, as the water level fluctuations are normal and expected in a water-seal drainage system. The water level should rise during inspiration and fall during expiration, reflecting the changes in intrathoracic pressure.
A client who received 6 units of packed red blood cells 3 days ago for a lower gastrointestinal (GI) bleed is now displaying signs of shortness of breath with occasional stridor and is reporting muscle cramping. Which serum laboratory value should the nurse immediately report to the healthcare provider?
- A. Potassium 4.7 mEq/L (4.70 mmol/L).
- B. Magnesium 2.1 mEq/L (0.86 mmol/L).
- C. Calcium 6.5 mg/dL (1.63 mmol/L).
- D. Sodium 135 mEq/L (135 mmol/L).
Correct Answer: C
Rationale: Calcium 6.5 mg/dL (1.63 mmol/L) is below the normal reference range and can cause muscle spasms, cramps, tingling, numbness, and stridor. This critical value should be immediately reported to the healthcare provider, as it can indicate a serious condition such as acute pancreatitis, sepsis, or massive blood transfusion.
A client with acute renal injury (AKI) weighs 110.3 pounds (50 kg) and has a potassium level of 6.7 mEq/L (6.7 mmol/L) is admitted to the hospital. Which prescribed medication should the nurse administer first?
- A. Sodium polystyrene sulfonate 15 grams by mouth.
- B. Sevelamer one tablet by mouth.
- C. Calcium acetate one tablet by mouth.
- D. Epoetin alfa, recombinant 2,500 units subcutaneously.
Correct Answer: A
Rationale: Sodium polystyrene sulfonate is a medication that binds to excess potassium in the gastrointestinal tract and removes it from the body through feces. It is used to treat hyperkalemia, which is a high level of potassium in the blood. Hyperkalemia can cause cardiac arrhythmias and muscle weakness, and it is a common complication of AKI. Therefore, this medication should be administered first to lower the potassium level and prevent life-threatening complications.