Nokea
An adult is receiving lithium carbonate 600 mg tid. Which of the following observations is of greatest concern to the nurse?
- A. The serum lithium level is 1.0 mEq/L.
- B. The client states that she is going to go on a low-sodium diet.
- C. The client has gaining 10 lb in the last three months.
- D. The client says, 'I always drink a lot of water when I take the pills.'
Correct Answer: B
Rationale: A low-sodium diet increases lithium retention, risking toxicity, a serious concern requiring immediate education or intervention.
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A client with acute glomerulonephritis requests a snack. Which snack is suitable given the client's dietary restrictions?
- A. Orange
- B. Banana
- C. Applesauce
- D. Raisins
Correct Answer: C
Rationale: Applesauce is a suitable snack for the client with acute glomerulonephritis. Answers A, B, and D are incorrect because oranges, bananas, and dried fruits such as raisins are high in potassium, which is restricted in the diet of the client with AGN.
An 18-year-old client with anorexia nervosa is admitted to the hospital.
In planning to care for the client, the nurse would expect the client to
- A. view her appearance as 'skinny.'
- B. be hypoactive and withdrawn.
- C. want to talk about and plan her meals.
- D. have a close relationship with her mother.
Correct Answer: C
Rationale: Strategy: Determine how each answer choice relates to anorexia. (1) usually view their appearance as fat (2) inaccurate for client with anorexia nervosa (3) correct-display a marked preoccupation with food (4) inaccurate for client with anorexia nervosa
The doctor writes an order for piperacillin (Pipracil) 3 g IV q6h for an adult client.
Before administering this drug, the nurse should
- A. check for known allergies to medications.
- B. ensure that the client's respiratory rate is over 12.
- C. administer dexamethasone sodium phosphate (Decadron) 2 mg IV stat.
- D. check the client's blood pressure both sitting and standing.
Correct Answer: A
Rationale: Strategy: Answers are a mix of assessments and implementations. Is this a situation that requires assessment? Yes. Is there an appropriate assessment? Yes. (1) correct-assessment, piperacillin (Pipracil) is a semisynthetic broad-spectrum penicillin, should not be administered to clients with known allergies (2) assessment, not relevant for administration of this medication (3) implementation, not relevant for administration of this medication (4) assessment, not relevant for administration of this medication
A 14-year-old client is scheduled for a below-knee (BK) amputation following a motorcycle accident. The nurse knows preoperative teaching for this client should include
- A. explaining that the client will be walking with a prosthesis soon after surgery.
- B. encouraging the client to share his feelings and fears about the surgery.
- C. taking the informed consent form to the client and asking him to sign it.
- D. evaluating how the client plans to maintain his schoolwork during hospitalization.
Correct Answer: B
Rationale: discussing his feelings and fears is important in dealing with his anxiety due to a change in body image and functioning
The nurse is caring for a client who is postoperative day 1 after a total hysterectomy. Which of the following findings would be of GREATest concern to the nurse?
- A. Temperature of 100.4°F (38°C).
- B. Pain at the incision site.
- C. Vaginal bleeding of 50 mL.
- D. Absence of bowel sounds.
Correct Answer: A
Rationale: A temperature of 100.4°F suggests infection, a serious complication post-hysterectomy requiring immediate evaluation. Options B, C, and D are expected: incision pain, minimal vaginal bleeding, and absent bowel sounds are normal on day 1.