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 nurse is providing an in service about client evacuation during a fire. Which of the following clients should the nurse instruct the staff to evacuate first?
- A. A client who uses a wheelchair and is confused
- B. A client who is bedridden and wears a hearing aid
- C. A client who is ambulatory and receiving oxygen
- D. A client who has a fracture and is in balance suspension traction
Correct Answer: A
Rationale: The correct answer is A because a client who uses a wheelchair and is confused is at the highest risk during a fire evacuation due to mobility limitations and decreased ability to follow instructions. Evacuating this client first ensures their safety and prevents potential delays in the evacuation process.
Choice B is incorrect because a bedridden client wearing a hearing aid can still be safely evacuated with assistance. Choice C is incorrect as an ambulatory client receiving oxygen can usually move independently and should be evacuated after the client in a wheelchair. Choice D is incorrect because a client with a fracture in traction can be safely moved with proper equipment and should not be the first priority for evacuation.
A nurse is inserting an indwelling urinary catheter for a male client. Which of the following actions should the nurse take?
- A. Perform the cleansing procedure with a fresh swab two times
- B. Pick up the catheter 13 cm (5 in) from its tip
- C. Cleanse the tip of the penis in a side-to-side motion
- D. Lift the penis so that it is perpendicular to the client's body
Correct Answer: D
Rationale: The correct answer is D: Lift the penis so that it is perpendicular to the client's body. This action helps in straightening the urethra, making it easier to insert the catheter. Lifting the penis perpendicular to the body also reduces the risk of trauma or injury during catheterization.
A, B, and C are incorrect because performing the cleansing procedure two times with a fresh swab, picking up the catheter 13 cm from its tip, and cleansing the tip of the penis in a side-to-side motion are not recommended practices and may increase the risk of contamination or injury.
A nurse in a clinic is planning care for a child who has ADHD and is taking atomoxetine. Which of the following laboratory values should the nurse monitor?
- A. Liver function tests
- B. Kidney function tests
- C. Hemoglobin and hematocrit
- D. Serum sodium and potassium
Correct Answer: A
Rationale: The correct answer is A: Liver function tests. Atomoxetine is known to potentially cause liver injury. Monitoring liver function tests is crucial to detect any signs of liver damage early on. Kidney function tests (B), hemoglobin and hematocrit (C), and serum sodium and potassium (D) are not directly associated with atomoxetine use in ADHD. Monitoring liver function is the priority in this case.
A nurse is assessing a client who is postoperative and has a history of pulmonary embolism. Which of the following findings is the priority for the nurse to report to the provider?
- A. Tachycardia
- B. Dry cough
- C. Dyspnea
- D. Hypotension
Correct Answer: C
Rationale: The correct answer is C: Dyspnea. Dyspnea in a postoperative client with a history of pulmonary embolism indicates a potential respiratory complication, which could be life-threatening. The priority is to report this finding to the provider for prompt evaluation and intervention to prevent further complications. Tachycardia (A) and hypotension (D) may also be concerning but dyspnea takes precedence due to its association with pulmonary embolism. A dry cough (B) may be a common postoperative symptom and not necessarily urgent.
Select the 5 actions the nurse should take.
- A. Increase the flowrate of the maintenance IV fluid
- B. Have the charge nurse notify the provider
- C. Place the client in a Trendelenburg position.
- D. Exert upward pressure on the presenting part.
- E. Attempt to push the umbilical cord back into the cervix
- F. Administer oxygen at 10 L/min via nonrebreather face mask
Correct Answer: B, C, D, E, F
Rationale: The correct actions (B, C, D, E, F) are based on managing a prolapsed umbilical cord during labor. B is crucial for timely intervention by involving the provider. C (Trendelenburg position) helps alleviate pressure on the cord. D (upward pressure) helps relieve compression on the cord. E aims to prevent cord compression. F (oxygen) supports fetal oxygenation. A is incorrect as increasing IV flowrate isn't a priority. G is not provided.