Nokea
Grace was diagnosed with hyperparathyroidism after a workup to determine the cause of her elevated calcium levels. The greatest concern in a patient with hypercalcemia would be:
- A. Cardiac arrhythmia and sinus arrest.
- B. Nausea and vomiting.
- C. Constipation and dehydration.
- D. Kidney stones and muscle weakness.
Correct Answer: D
Rationale: The correct answer is Kidney stones and muscle weakness (D). Hypercalcemia is commonly associated with kidney stones due to increased calcium excretion in urine. Muscle weakness is also a common symptom due to the effect of high calcium levels on neuromuscular function.
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A client with diabetes is experiencing symptoms of hypoglycemia. What should the nurse administer first?
- A. 10 units of regular insulin subcutaneously
- B. 50 mL of 50% dextrose solution intravenously
- C. 1 mg of glucagon intramuscularly
- D. 15-20 grams of fast-acting carbohydrate orally
Correct Answer: D
Rationale: The correct answer is D: 15-20 grams of fast-acting carbohydrate orally. In hypoglycemia, the immediate goal is to raise blood glucose levels quickly. Fast-acting carbohydrates like glucose tablets or juice are the most effective and fastest way to raise blood sugar levels. Administering insulin (choice A) would further lower blood sugar levels. Intravenous dextrose (choice B) is appropriate for severe cases but may not be necessary as the first step. Glucagon (choice C) is typically used if the client is unconscious or unable to consume oral carbohydrates.
On assessment of a patient’s learning needs, the nurse determines that a patient taking potassium-wasting diuretics does not know what foods are high in potassium. What is an appropriate nursing diagnosis for this patient?
- A. Risk for cardiac dysrhythmias related to low potassium intake
- B. Deficient knowledge related to not knowing what foods are high in potassium
- C. Imbalanced nutrition: less than body requirements related to lack of intake of potassium-rich foods
- D. Deficient knowledge related to lack of interest regarding dietary requirements when taking diuretics
Correct Answer: B
Rationale: The correct answer is 'Deficient knowledge related to not knowing what foods are high in potassium.' This nursing diagnosis directly addresses the identified learning need. While other options may be indirectly relevant, the primary issue here is the patient's lack of knowledge about potassium-rich foods.
A client who is intubated and has an intra-aortic balloon pump is restless and agitated. What action should the nurse perform first for comfort?
- A. Allow family members to remain at the bedside.
- B. Ask the family if the client would like a fan in the room.
- C. Keep the television tuned to the client's favorite channel.
- D. Speak loudly to the client in case of hearing problems.
Correct Answer: A
Rationale: The correct answer is A: Allow family members to remain at the bedside. This is the priority action as it provides emotional support and comfort to the client. Having familiar faces around can help calm the client and reduce agitation. It also promotes a sense of security and connection.
Choices B, C, and D are incorrect because they do not address the client's immediate need for comfort and emotional support. Asking about a fan, tuning the TV, or speaking loudly do not directly address the client's restlessness and agitation. Prioritizing the presence of family members is essential in this situation.
What is one reason that might apply to a client’s rationale for using alternative therapy?
- A. Desire to become more active in decision-making and self-care.
- B. Chronic incurable back condition.
- C. Difficulty meeting the rising costs of healthcare.
- D. Client does not share traditional American health beliefs and practices.
Correct Answer: A
Rationale: Clients often seek alternative therapies to take a more active role in their healthcare decisions and self-management.
What best describes Mrs. West’s change in vital signs postoperatively?
- A. Decrease in BP indicates shock is imminent
- B. Elevated temperature indicates wound infection
- C. Decrease in BP is consistent with hypertension
- D. Elevation in temperature is consistent with normal postoperative recovery
Correct Answer: D
Rationale: A mild fever is common after surgery due to inflammatory response.