Nokea
The client's laboratory results indicate that the serum potassium level is 2.5 mEq/L (2.5 mmol/L). Which action should the nurse take?
- A. Prepare to administer a glucose, then insulin, then potassium infusion.
- B. Inform the healthcare provider of the need for potassium replacement.
- C. Instruct the client to Increase dally Intake of potassium rich foods.
- D. Change the plan of care to Include hourly urinary output measurements.
Correct Answer: B
Rationale: Severe hypokalemia requires immediate potassium replacement, necessitating healthcare provider notification, rather than dietary changes or monitoring alone.
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The nurse is evaluating a client's symptoms, and formulates the nursing problem, 'High risk for injury due to potential urinary tract infection.' Which symptoms indicate the need for this nursing problem?
- A. Straining on urination and nocturia
- B. Azotemia and anorexia.
- C. Hematuria and proteinuria.
- D. Fever and dysuria.
Correct Answer: D
Rationale: Fever and dysuria are classic UTI symptoms, indicating a risk for serious complications like pyelonephritis or sepsis. Other options suggest urinary issues but are less directly linked to injury risk.
A client is receiving a secondary infusion of vancomycin 1,500 mg in 250 ml to be infused over two hours. The IV administration set delivers 15 gtt/mL. How many gtt/min should the nurse regulate the Infusion? (Enter numerical value only. If rounding is required, round to the nearest whole number.)
Correct Answer: 31
Rationale: Using the formula (250 mL x 15 gtt/mL) / 120 min = 31.25 gtt/min, rounded to 31 gtt/min.
History and Physical
Nurses' Notes
Orders
Imaging Studies
The client is a young male who appears to be 25 to 30 years old. He was found unconscious on a sidewalk by a jogger who was passing by. The jogger called an ambulance, and the emergency medical technicians (EMTS) transported the client to the hospital. The client is arousable but unable to say what his name is or what happened to him. A STAT head computed tomography (CT) scan in the emergency department showed no abnormalities, so the client will be admitted to the medical floor for observation and further tests.
The nurse identifies that the client is having a tonic clonic seizure. The oxygen saturation is 40% and the respiratory rate is 4 breaths/minute. The nurse calls for help and 2 other nurses enter the room. Which 3 interventions should be performed first?
- A. Place pillows around the bed rails to provide padding.
- B. Watch the seizure activity and document the time and client movement.
- C. Manually ventilate the client with a bag-valve mask (BVM).
- D. Stop the IV fluids.
- E. Increase the supplemental oxygen to 10 L/minute via nasal cannula.
- F. Begin chest compressions.
Correct Answer: B,C,E
Rationale: Ventilation, oxygen increase, and seizure monitoring address hypoxia and safety during a tonic-clonic seizure.
An adult client is admitted to the medical unit due to rectal bleeding after a colonoscopy in which a polyp was biopsied and cauterized. Which Intervention should the nurse do first?
- A. Palpate all peripheral pulses in the extremities.
- B. Encourage cough and deep breathing exercises.
- C. Complete a focused assessment of the abdomen.
- D. Initiate measurement of fluid intake and output.
Correct Answer: C
Rationale: A focused abdominal assessment determines the severity of bleeding and guides further interventions, prioritizing over pulses, respiratory exercises, or fluid monitoring.
A client with a large pleural effusion undergoes a thoracentesis. Following the procedure, which observation warrants immediate intervention by the nurse?
- A. The client's chest x-ray Indicates decreased pleural effusion.
- B. The client's arterial blood gas result is a pH 7.35, PaCO, 35 mm Hg, HCO,-26 mEq (26 mmol/L), PaO, 85 mm Hg.
- C. The client has asymmetrical chest wall expansion.
- D. The client reports pain at the insertion site.
Correct Answer: C
Rationale: Asymmetrical chest wall expansion may indicate pneumothorax, a serious complication requiring immediate intervention.