Nokea
The client who is scheduled for a knee replacement asks the nurse why she should donate her own blood before surgery. How should the nurse respond?
- A. The blood bank is very short of blood.'
- B. Your own blood is the correct type for you.'
- C. It eliminates the chance of blood-borne diseases such as hepatitis and HIV.'
- D. Your own blood increases your energy level after surgery.'
Correct Answer: C
Rationale: Autologous blood donation eliminates transfusion-related infection risks, like hepatitis or HIV, ensuring safety during surgery.
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The nurse is caring for a client with a history of chronic kidney disease.
- A. Which dietary restriction is most important for a client with chronic kidney disease?
- B. Low-sodium diet.
- C. Low-carbohydrate diet.
- D. High-protein diet.
- E. High-fat diet.
Correct Answer: A
Rationale: A low-sodium diet reduces fluid retention and hypertension in chronic kidney disease. Protein is restricted, carbohydrates are encouraged, and high-fat diets are not indicated.
An elderly client is oriented during the day but becomes disoriented during the evening.
Which of the following nursing actions is MOST appropriate?
- A. Place a clock where the client can see it.
- B. Restrain all four extremities.
- C. Keep a light on in the client's room.
- D. Place the side rails in an upright position.
Correct Answer: D
Rationale: Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) will provide visual cues, safety is more important (2) inappropriate (3) may be appropriate, but is not priority over answer choice #4 (4) correct-side rails should always be in an upright position for a disoriented client
The nurse is teaching a client with a new diagnosis of epilepsy about lamotrigine (Lamictal). Which of the following statements by the client indicates a need for further teaching?
- A. I should report a rash to my doctor.
- B. I should take this medication at the same time each day.
- C. I should avoid drinking alcohol.
- D. I should stop this medication if my seizures stop.
Correct Answer: D
Rationale: Stopping lamotrigine when seizures stop is incorrect, as epilepsy often requires lifelong treatment to prevent recurrence. Options A, B, and C are correct: rash may indicate Stevens-Johnson syndrome, consistent timing ensures steady levels, and alcohol increases sedation.
The nurse is caring for a client with a history of atrial fibrillation who is receiving digoxin (Lanoxin) 0.125 mg PO daily. Which of the following laboratory results would be of GREATest concern to the nurse?
- A. Potassium 3.0 mEq/L.
- B. Sodium 140 mEq/L.
- C. Magnesium 2.0 mEq/L.
- D. Calcium 9.0 mg/dL.
Correct Answer: A
Rationale: Hypokalemia (potassium 3.0 mEq/L) increases the risk of digoxin toxicity, which can cause life-threatening arrhythmias in atrial fibrillation. Options B, C, and D are normal: sodium 140 mEq/L, magnesium 2.0 mEq/L, and calcium 9.0 mg/dL do not affect digoxin.
The nurse is teaching a client with a new diagnosis of atrial fibrillation about diltiazem (Cardizem). Which of the following instructions should the nurse include?
- A. Take the medication with grapefruit juice.
- B. Report any swelling in the legs.
- C. Stop the medication if heart rate normalizes.
- D. Avoid checking pulse rate.
Correct Answer: B
Rationale: Swelling in the legs may indicate heart failure, requiring reporting. Options A, C, and D are incorrect.