Nokea
Complete the following sentence by using the lists of options. The nurse understands that the patient has likely developed-----and will need to be monitored for-------
- A. Lithium toxicity
- B. Hyponatremia
- C. cardiac dysrhythmias
- D. nephrotoxicity
- E. metabolic alkalosis
- F. Hypertension
Correct Answer: A,D
Rationale: The correct answer is A and D. Lithium toxicity and nephrotoxicity are commonly associated with the use of lithium. The nurse needs to monitor the patient for signs and symptoms of lithium toxicity, such as tremors, confusion, and increased thirst, as well as signs of nephrotoxicity, like decreased urine output and electrolyte imbalances. Hyponatremia (B), cardiac dysrhythmias (C), metabolic alkalosis (E), and hypertension (F) are not directly related to lithium use. Monitoring for these conditions would not be the priority in a patient who has likely developed lithium toxicity and nephrotoxicity.
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A charge nurse is teaching a newly licensed nurse about medication administration. Which of the following information should the charge nurse include?
- A. Avoid preparing medications for more than two clients at one time
- B. Complete an incident report if a client vomits after taking a medication
- C. Inform clients about the action of each medication prior to administration
- D. Read medication labels at least two times prior to administration
Correct Answer: C
Rationale: The correct answer is C: Inform clients about the action of each medication prior to administration. This is important for promoting patient safety and informed consent. By educating clients about their medications, nurses empower them to be active participants in their own care and help prevent medication errors. Option A is incorrect because preparing medications for multiple clients simultaneously can increase the risk of errors. Option B is incorrect as vomiting after medication administration should be reported to the healthcare provider, not necessarily as an incident report. Option D is incorrect as reading medication labels only once may lead to oversight of important information.
A nurse is planning care for a client who sustained a major burn over 20% of the body. Which of the following interventions should the nurse include to support the client's nutritional requirements?
- A. Maintain calorie intake at 1,500 per day
- B. Provide a low-protein, high-carbohydrate diet.
- C. Keep a calorie count for foods and beverages.
- D. Schedule meals at 6-hr intervals
Correct Answer: C
Rationale: The correct answer is C: Keep a calorie count for foods and beverages. For a client with major burn injuries, accurate monitoring of calorie intake is crucial to support nutritional requirements for wound healing and metabolic demands. This intervention allows the nurse to adjust the diet as needed to meet the client's energy needs. Choice A is incorrect as calorie intake requirements may vary based on individual needs. Choice B is incorrect as a high-protein diet is essential for wound healing in burn patients. Choice D is incorrect as frequent, smaller meals are typically recommended for burn patients to support healing and prevent muscle breakdown.
A nurse is assessing a client who has histrionic personality disorder. Which of the following manifestations should the nurse expect?
- A. Suspicious of others
- B. Callousness
- C. Self-centered behavior
- D. Violates other's rights
Correct Answer: C
Rationale: The correct answer is C: Self-centered behavior. Individuals with histrionic personality disorder typically exhibit attention-seeking, dramatic, and overly emotional behaviors. They often crave approval and validation from others, focusing on themselves and their own needs. This behavior aligns with the core characteristics of histrionic personality disorder.
Choice A (Suspicious of others) is incorrect as suspicion is not a defining trait of histrionic personality disorder. Choice B (Callousness) is inconsistent as histrionic individuals tend to be overly emotional rather than callous. Choice D (Violates other's rights) is not a common feature of histrionic personality disorder.
In summary, the nurse should expect self-centered behavior in a client with histrionic personality disorder, as they typically display attention-seeking and dramatic behaviors, seeking validation and approval from others.
A nurse is discussing discharge plans with an older adult client who lives alone and has left-sided weakness following a stroke. Which of the following information is the priority for the nurse to discuss?
- A. Reviewing information about support groups for individuals who have had a stroke
- B. Obtaining an alert system to get help in case of a fall
- C. Providing information about available transportation resources
- D. Choosing an agency to provide home physical therapy
Correct Answer: B
Rationale: The correct answer is B: Obtaining an alert system to get help in case of a fall. This is the priority because the client's left-sided weakness puts them at risk for falls, which can have serious consequences. Having an alert system ensures they can get immediate help if a fall occurs, potentially preventing injuries or complications. Reviewing support groups (A) can be beneficial but is not as urgent. Providing transportation resources (C) and choosing a home physical therapy agency (D) are important but do not address the immediate safety concern of potential falls.
A nurse in an emergency department is caring for a 3-year-old child who has suspected epiglottitis. Which of the following actions should the nurse take?
- A. Prepare to assist with intubation.
- B. Obtain a throat culture.
- C. Suction the child's oropharynx.
- D. Prepare a cool mist tent
Correct Answer: A
Rationale: The correct answer is A: Prepare to assist with intubation. Epiglottitis is a medical emergency where the swelling of the epiglottis can rapidly obstruct the airway, leading to respiratory distress or failure. Intubation is crucial to secure the airway and ensure adequate oxygenation. Obtaining a throat culture (B) may delay necessary intervention. Suctioning the oropharynx (C) can trigger spasm and worsen the obstruction. Cool mist tent (D) does not address the immediate need for securing the airway.