Nokea
An adult is admitted with nausea, vomiting, and diarrhea. The client is receiving an IV of dextrose 5% in water with 40 mEq of KCl. The nurse knows the potassium is added to do which of the following?
- A. Replace potassium lost because of vomiting and diarrhea
- B. Replace potassium that the client is not getting from his diet
- C. Stop the nausea
- D. Stop the diarrhea
Correct Answer: A
Rationale: Vomiting and diarrhea cause significant potassium loss, requiring IV potassium replacement to prevent hypokalemia.
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The spouse of a client with Alzheimer's disease expresses concern about the burden of caregiving. Which of the following actions by the nurse should be a priority?
- A. Link the caregiver with a support group
- B. Ask friends to visit regularly
- C. Schedule a home visit each week
- D. Request anti-anxiety prescriptions
Correct Answer: A
Rationale: Assisting caregivers to locate and join support groups is most helpful. Families share feelings and learn about services such as respite care. Health education is also available through local and national Alzheimer's chapters.
The nurse has reinforced teaching with a client with newly diagnosed polycythemia vera. Which of the following statements by the client would require follow-up?
- A. I should take an iron supplement daily.'
- B. I should increase my daily fluid intake.'
- C. I may require frequent phlebotomy.'
- D. I will take a low-dose aspirin daily.'
Correct Answer: A
Rationale: Iron supplements (A) can worsen polycythemia vera by increasing red blood cell production, requiring follow-up. Increased fluids (B), phlebotomy (C), and aspirin (D) are appropriate.
A very tall, heavy-set man is admitted. The nurse is taking vital signs. Which statement is correct concerning taking the blood pressure?
- A. 10 mm should be added to each reading to compensate for the cuff size.
- B. 15 mm should be subtracted from the systolic reading, and 10 mm should be subtracted from the diastolic reading.
- C. An extra-large cuff is needed to obtain an accurate measurement.
- D. The client should lie down before the blood pressure is taken.
Correct Answer: C
Rationale: An extra-large cuff ensures accurate blood pressure measurement in large individuals; a standard cuff falsely elevates readings. Adjusting readings or lying down is unnecessary.
The nurse reinforces teaching about methotrexate to a client with rheumatoid arthritis. It is most important to address which topic regarding this drug?
- A. Need for an eye examination
- B. Need for sunblock
- C. Risk for infection
- D. Risk for kidney injury
Correct Answer: C
Rationale: Methotrexate suppresses the immune system, significantly increasing the risk for infection (C). This is a critical teaching point to ensure the client takes precautions. Eye exams (A), sunblock (B), and kidney injury (D) are less directly associated with methotrexate's primary risks.
The nurse is making assignments for the day's care. Which assignment should not be given to the nursing assistant?
- A. Emptying the Foley catheter bag
- B. Administering a Fleet's enema
- C. Measuring the oral intake
- D. Feeding a client with depression
Correct Answer: B
Rationale: Administering an enema requires nursing judgment and is outside a nursing assistant's scope. Other tasks are appropriate for a nursing assistant.