Nokea
Laboratory findings indicate that a client's serum potassium level is 2.5 mEq/L. What action should the nurse take?
- A. Administer potassium supplements orally.
- B. Increase the client's dietary potassium intake.
- C. Inform the healthcare provider of the need for potassium replacement.
- D. Monitor the client's ECG continuously.
Correct Answer: C
Rationale: A serum potassium level of 2.5 mEq/L is critically low, indicating severe hypokalemia. In this situation, it is essential for the nurse to inform the healthcare provider promptly about the need for potassium replacement. Administering potassium supplements orally or increasing dietary potassium intake is not appropriate in cases of critically low potassium levels as immediate and precise replacement is necessary. Monitoring the client's ECG continuously is important in severe cases of hypokalemia, but the priority action should be to inform the healthcare provider for further management and treatment.
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In planning care for a postoperative client with hypovolemic shock, which problem is most important to include in the plan of care?
- A. Risk for infection.
- B. Risk for falls.
- C. Impaired skin integrity.
- D. Activity intolerance.
Correct Answer: B
Rationale: The correct answer is B: Risk for falls. In a postoperative client with hypovolemic shock, the most crucial problem to address is the risk for falls. Hypovolemic shock can result in dizziness and weakness, making the client prone to falling. Preventing falls is essential to avoid further injury or complications. Choices A, C, and D are not the top priority in this scenario. While infection, impaired skin integrity, and activity intolerance are important concerns, preventing falls takes precedence due to the immediate risk of injury associated with hypovolemic shock.
After a CT scan with intravenous contrast medium, a client returns to the room complaining of shortness of breath and itching. Which intervention should the nurse implement?
- A. Call respiratory therapy to administer a breathing treatment.
- B. Send for an emergency tracheostomy set.
- C. Prepare a dose of epinephrine.
- D. Review the client's complete list of allergies.
Correct Answer: C
Rationale: Preparing a dose of epinephrine is the correct intervention in this situation as the client is displaying symptoms of an anaphylactic reaction to the contrast medium used during the CT scan. Epinephrine is the first-line treatment for anaphylaxis due to its ability to reverse the symptoms rapidly. Calling respiratory therapy for a breathing treatment (Choice A) may not address the underlying allergic reaction and delay appropriate treatment. Sending for an emergency tracheostomy set (Choice B) is not indicated as the client's symptoms suggest an allergic reaction rather than airway obstruction. Reviewing the client's complete list of allergies (Choice D) is important but would not provide immediate relief for the client's current symptoms; administering epinephrine takes precedence in this situation.
How should the nurse record the observation of a child with Duchenne muscular dystrophy rising from the floor by walking up the thighs with the hands?
- A. Hand assistance
- B. Leg crawling
- C. Gowers sign
- D. Bright sign
Correct Answer: C
Rationale: The correct term for a child with Duchenne muscular dystrophy rising from the floor by walking up the thighs with the hands is known as the Gowers sign. This maneuver is characteristic of Duchenne muscular dystrophy due to proximal muscle weakness. Choices A, B, and D are incorrect because they do not specifically describe the action of walking up the thighs with the hands, which is a distinctive feature of the Gowers sign.
A client admitted with left-sided heart failure has a heart rate of 110 beats per minute and is becoming increasingly dyspneic. Which additional assessment finding by the nurse supports the client's admitting diagnosis?
- A. Jugular vein distention.
- B. Crackles in the lung bases.
- C. Peripheral edema.
- D. Bounding peripheral pulses.
Correct Answer: B
Rationale: The correct answer is B: Crackles in the lung bases. Crackles in the lung bases are indicative of pulmonary congestion, which is a classic sign of left-sided heart failure. Left-sided heart failure leads to a backup of blood into the lungs, causing fluid leakage into the alveoli and resulting in crackles upon auscultation. Choices A, C, and D are less specific to left-sided heart failure. Jugular vein distention can be seen in right-sided heart failure, peripheral edema can be seen in both right and left-sided heart failure, and bounding peripheral pulses are more indicative of conditions like hyperthyroidism or anemia rather than specifically supporting left-sided heart failure.
Which nursing intervention is most important for the nurse to implement when caring for an older client who is legally blind?
- A. Keep the room well-lit at all times.
- B. Speak to the client each time the nurse enters the room.
- C. Ensure the client wears glasses at all times.
- D. Provide written instructions in large print.
Correct Answer: B
Rationale: The correct answer is to speak to the client each time the nurse enters the room. This intervention is crucial for orienting and reassuring the client, promoting safety, and facilitating communication. Keeping the room well-lit (Choice A) can be helpful but is not as essential as direct verbal communication. Ensuring the client wears glasses (Choice C) may not be feasible or necessary for someone who is legally blind. Providing written instructions in large print (Choice D) is not effective for a client with visual impairments.