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The client diagnosed with inflammatory bowel disease has a serum potassium level of 3.4 mEq/L. Which action should the nurse implement first?
- A. Notify the health-care provider (HCP).
- B. Assess the client for muscle weakness.
- C. Request telemetry for the client.
- D. Prepare to administer potassium IV.
Correct Answer: B
Rationale: A potassium level of 3.4 mEq/L is slightly low, warranting assessment for symptoms like muscle weakness, which could indicate hypokalemia severity. Notification or intervention would follow based on clinical findings, but assessment is the first step.
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Which statement made by the client indicates to the nurse the client may be experiencing GERD?
- A. My chest hurts when I walk up the stairs in my home.
- B. I take antacid tablets with me wherever I go.
- C. My spouse tells me I snore very loudly at night.
- D. I drink six (6) to seven (7) soft drinks every day.
Correct Answer: B
Rationale: Frequent use of antacids suggests ongoing heartburn or reflux symptoms, a hallmark of GERD. Chest pain with exertion is more suggestive of cardiac issues, snoring may indicate sleep apnea, and soft drink consumption is a risk factor but not a direct symptom.
Which priority teaching information should the nurse discuss with the client to help prevent contracting hepatitis B?
- A. Explain the importance of good hand washing.
- B. Recommend the client take the hepatitis B vaccine.
- C. Tell the client not to ingest unsanitary food or water.
- D. Discuss how to implement Standard Precautions.
Correct Answer: B
Rationale: The hepatitis B vaccine is the most effective way to prevent hepatitis B, a bloodborne virus. Handwashing and food safety are less relevant, and Standard Precautions are for healthcare settings.
Which assessment question is priority for the nurse to ask the client diagnosed with end-stage liver failure secondary to alcoholic cirrhosis?
- A. How many years have you been drinking alcohol?
- B. Have you completed an advance directive?
- C. When did you have your last alcoholic drink?
- D. What foods did you eat at your last meal?
Correct Answer: C
Rationale: Recent alcohol consumption can exacerbate liver failure and affect treatment decisions, making it the priority question. Duration of drinking, advance directives, and diet are secondary.
The nurse is admitting a client diagnosed with protein calorie malnutrition. Which interventions should the nurse implement? Select all that apply.
- A. Place the client on a 72-hour calorie count.
- B. Ask the client to describe the stools.
- C. Have the UAP weigh the client.
- D. Obtain a list of current medications.
- E. Make a referral to the dietitian.
Correct Answer: A,C,D,E
Rationale: Calorie count, weight, medication list, and dietitian referral assess and manage malnutrition. Stool description is less relevant unless GI issues are present.
Following a hemorrhoidectomy, the nurse is instructing the client in self-care. Which statement is especially important to include in these instructions?
- A. Wash the anal area with water after defecation and pat it dry.'
- B. Gently wipe the anal area after defecation from back to front.'
- C. Do not drink more than three glasses of fluid per day until after you have had the first bowel movement.'
- D. When you first feel the need to defecate, call me and I will give you the enema the doctor has ordered.'
Correct Answer: A
Rationale: Washing and patting dry promotes hygiene and healing post-hemorrhoidectomy, reducing irritation.