Nokea
Before the nurse administers I.V. replacement of 5% dextrose in water with potassium chloride, what nursing intervention must be completed first?
- A. Adding potassium chloride to the bag at the bedside
- B. Evaluating laboratory results for electrolytes
- C. Priming tubing using sterile technique
- D. Checking the rate for I.V. push administration
Correct Answer: B
Rationale: Evaluating electrolyte levels, especially potassium, is critical before administering potassium chloride to prevent hyperkalemia. Adding potassium at the bedside is unsafe, and priming or checking rates follows.
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The nurse is reviewing the care plan of a client diagnosed with having the deficits associated with a right-sided stroke. The nurse notes documentation that the client has unilateral neglect with left-sided deficits. The nurse plans care with the understanding that which action would be least helpful?
- A. Place bedside articles on the left side.
- B. Approach the client from the right side.
- C. Teach the client to scan the environment.
- D. Move the commode and chair to the left side.
Correct Answer: B
Rationale: Unilateral neglect is an unawareness of the paralyzed side of the body, which increases the client's risk for injury. The nurse's role is to refocus the client's attention to the affected side. Personal care items, belongings, a bedside chair, and a commode are all placed on the affected side. The client is taught to scan the environment to become aware of that half of the body and is approached on that side by family and caregivers as well.
The nurse is caring for a client with a fracture of a long bone. Which of the following assessments would be the earliest symptom of a fat embolism?
- A. Respiratory distress.
- B. Confusion.
- C. Petechiae.
- D. Fever.
Correct Answer: A
Rationale: Respiratory distress is the earliest symptom of fat embolism syndrome, as emboli obstruct pulmonary circulation, leading to hypoxia.
The nurse is caring for a client who has just undergone a mastectomy. Which of the following interventions is most important in the immediate postoperative period?
- A. Encourage arm exercises on the affected side.
- B. Keep the affected arm dependent.
- C. Apply heat to the surgical site.
- D. Restrict fluid intake.
Correct Answer: A
Rationale: Encouraging arm exercises prevents lymphedema and promotes circulation post-mastectomy.
The primary distinguishing characteristic of risk management when compared and contrasted to performance improvement is that risk management activities focus on:
- A. Historical data and performance improvement activities focus on current data.
- B. Current data and performance improvement activities focus on historical data.
- C. Decreasing financial liability and performance improvement activities focus on process improvements.
- D. Decreasing falls and performance improvement activities focus on process improvements.
Correct Answer: C
Rationale: Risk management focuses on decreasing financial liability by mitigating risks, while performance improvement focuses on enhancing processes and outcomes.
Which of the following outcomes is most appropriate for a nursing diagnosis of Ineffective tissue perfusion related to interruption of arterial flow? Select all that apply.
- A. Extremities warm to touch.
- B. Improved respiratory status.
- C. Decreased muscle pain with activity.
- D. Participation in self-care measures.
- E. Lungs clear to auscultation.
Correct Answer: A,C,D
Rationale: Warm extremities, reduced muscle pain, and self-care participation indicate improved perfusion; respiratory outcomes are unrelated.