Nokea
The client with cirrhosis of the liver is receiving Lactulose. The nurse is aware that the rationale for the order for Lactulose is:
- A. To lower the blood glucose level
- B. To lower the uric acid level
- C. To lower the ammonia level
- D. To lower the creatinine level
Correct Answer: C
Rationale: Lactulose is administered to the client with cirrhosis to lower ammonia levels, as it works by acidifying the colon, trapping ammonia for elimination in the stool. Choices A, B, and D are incorrect because Lactulose does not have an effect on blood glucose, uric acid, or creatinine levels. Therefore, the correct answer is to lower the ammonia level.
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Upon arrival at the emergency room, the client presents with severe burns to the left arm, hands, face, and neck. What action should take priority?
- A. Starting an IV
- B. Applying oxygen
- C. Obtaining blood gases
- D. Medicating the client for pain
Correct Answer: B
Rationale: In a client with severe burns to the face and neck, airway assessment and supplemental oxygen are crucial. Therefore, applying oxygen is the priority to ensure adequate oxygenation for the client. This intervention takes precedence over other actions to stabilize the client's condition. Starting an IV for fluid resuscitation is the next appropriate step following ensuring oxygenation (Choice A). While pain management is important, it is a secondary priority after ensuring oxygenation and fluid resuscitation, making medicating the client for pain a later intervention (Choice D). Obtaining blood gases (Choice C) is not the immediate priority in this scenario and would typically be ordered by the healthcare provider based on the client's condition and response to initial interventions.
While the client is receiving total parenteral nutrition (TPN), which lab test should be evaluated?
- A. Hemoglobin
- B. Creatinine
- C. Blood glucose
- D. White blood cell count
Correct Answer: C
Rationale: When a client is receiving total parenteral nutrition (TPN), monitoring blood glucose levels is crucial as TPN solutions contain high amounts of glucose. This monitoring helps prevent hyperglycemia or hypoglycemia. Evaluating hemoglobin (choice A) is not directly related to TPN administration. Creatinine (choice B) is more relevant for assessing kidney function. White blood cell count (choice D) is important for evaluating immune function and infection, but not specifically tied to TPN administration.
In the context of milieu therapy, what is its primary purpose?
- A. exploring the client's perception of reality
- B. enhancing social interaction abilities
- C. addressing maladaptive behaviors
- D. providing routine daily experiences
Correct Answer: D
Rationale: Milieu therapy aims to provide routine daily experiences to clients. By offering a structured and predictable environment, it helps individuals feel safe and secure, reducing disruptive behaviors. Exploring the client's perception of reality (choice A) may be part of therapy but not the primary focus. Enhancing social interaction abilities (choice B) and addressing maladaptive behaviors (choice C) are important aspects of therapy but not the primary purpose of milieu therapy.
A client with suspected renal disease is to undergo a renal biopsy. The nurse plans to include which statement in the teaching session?
- A. "You will be positioned lying down during the examination procedure."?
- B. "Portions of the procedure will cause pain or discomfort."?
- C. "You may be given anesthesia during the procedure."?
- D. "You should refrain from eating or drinking before the procedure."?
Correct Answer: B
Rationale: The correct answer is to inform the client that portions of the renal biopsy procedure can cause pain or discomfort, particularly when the sample is being withdrawn. This prepares the client for any unpleasant sensations during the procedure. Answer A is incorrect because the client will be positioned lying down, not sitting up, during the exam, so this information is not relevant to include in the teaching session. Answer C is incorrect as anesthesia is commonly used to numb the area for a renal biopsy, reducing pain, so the client can expect to receive anesthesia. Answer D is incorrect because clients are usually instructed to refrain from eating or drinking for a period before the procedure to prevent any complications during the biopsy, not simply before the study.
The client with schizophrenia has become disruptive and requires seclusion. Which staff member can institute seclusion?
- A. The security guard
- B. The registered nurse
- C. The licensed practical nurse
- D. The nursing assistant
Correct Answer: B
Rationale: The registered nurse is the correct choice to institute seclusion for a client with schizophrenia. In healthcare settings, only a registered nurse or a physician can legally initiate seclusion. The security guard, licensed practical nurse, and nursing assistant do not have the authority to carry out this action. Therefore, options A, C, and D are incorrect.