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The client returns to the unit from surgery with a blood pressure of 90/50, pulse 132, respirations 30. Which action by the nurse should receive priority?
- A. Document the finding.
- B. Contact the physician.
- C. Elevate the head of the bed.
- D. Administer a pain medication.
Correct Answer: B
Rationale: The vital signs indicate shock, so contacting the physician for immediate intervention is the priority.
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A nurse is working in a residential facility when a fire breaks out in one hallway. The nurse and an elderly client are trapped in the client's room and cannot get out. The nurse should
- A. crawl in the closet with the client and shut the door.
- B. open a window in the client's room.
- C. instruct the client to crawl under the bed.
- D. leave the door to the room open.
Correct Answer: B
Rationale: Opening a window provides ventilation and a potential escape route while avoiding smoke inhalation. Keeping the door closed prevents smoke entry, and crawling under the bed or in a closet is unsafe.
The nurse is caring for a client hospitalized with bipolar disorder, manic phase who is taking lithium. Which of the following snacks would be best for the client with mania?
- A. Potato chips
- B. Diet cola
- C. Apple
- D. Milkshake
Correct Answer: C
Rationale: An apple is a healthy, low-sodium snack, suitable for a client on lithium, as high sodium foods like potato chips can affect lithium levels.
The nurse is teaching a client with a new diagnosis of heart failure about sodium restriction. Which of the following foods should the client avoid?
- A. Fresh apples.
- B. Canned soups.
- C. Baked chicken.
- D. Brown rice.
Correct Answer: B
Rationale: canned soups are high in sodium, which should be limited in heart failure to prevent fluid retention
The nurse is caring for a client who has a lithium level of 2.2 mEq/L. Based on this lab value, what would the nurse anticipate to do in order to care for this client? Select all that apply.
- A. prepare to administer IV fluids
- B. notify the health care provider
- C. order a mechanical soft diet for the client
- D. administer the next dose of lithium when it is due
- E. observe the client for confusion and slurred speech
Correct Answer: A, B, E
Rationale: A lithium level of 2.2 mEq/L indicates toxicity (therapeutic range: 0.6–1.2 mEq/L). The nurse should prepare IV fluids, notify the provider, and monitor for symptoms like confusion and slurred speech. A soft diet is unnecessary, and the next dose should be held.
The doctor has prescribed Cortone (cortisone) for a client with systemic lupus erythematosis. Which instruction should be given to the client?
- A. Take the medication 30 minutes before eating.
- B. Report changes in appetite and weight.
- C. Wear sunglasses to prevent cataracts.
- D. Schedule a time to take the influenza vaccine.
Correct Answer: B
Rationale: Cortisone can cause weight gain and appetite changes, which should be monitored in SLE to manage side effects.