Nokea
The healthcare professional is preparing to administer potassium chloride intravenously to a client with hypokalemia. Which action is most important?
- A. Monitor the client's respiratory rate
- B. Check the client's urine output
- C. Administer the potassium chloride as a rapid IV push
- D. Dilute the potassium chloride in an appropriate IV solution
Correct Answer: D
Rationale: The correct answer is to dilute the potassium chloride in an appropriate IV solution. Potassium chloride should never be administered as a rapid IV push as it can lead to severe complications, including cardiac arrhythmias. Diluting the medication and administering it slowly helps reduce the risk of adverse effects. Monitoring the client's respiratory rate (Choice A) and checking urine output (Choice B) are important aspects of patient assessment but not the most crucial when administering potassium chloride. Administering potassium chloride as a rapid IV push (Choice C) is dangerous and can result in serious harm to the client.
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A client requires an NG tube for stomach decompression. Which of the following actions should the nurse take when inserting the NG tube?
- A. Help the client take sips of water to promote insertion of the NG tube.
- B. Insert the tube without asking the client to swallow.
- C. Advance the tube continuously without pausing.
- D. Use a large-bore tube for insertion.
Correct Answer: A
Rationale: The correct action when inserting an NG tube is to help the client take sips of water. This helps facilitate the insertion of the tube by promoting swallowing and passage through the esophagus. Asking the client to swallow assists in guiding the tube into the stomach. Inserting the tube without asking the client to swallow may lead to incorrect placement or discomfort. Advancing the tube continuously without pausing can cause the tube to coil in the esophagus, leading to complications. Using a large-bore tube for insertion is unnecessary and may increase the risk of injury or discomfort for the client.
A nurse on a rehabilitation unit is transferring a client from a bed to a chair. To avoid a back injury, which of the following techniques should the nurse use?
- A. Bend at the knees while maintaining a wide stance and a straight back, with the client's hands on the nurse's shoulders, and the nurse's hands under the client's axillae
- B. Use a mechanical lift
- C. Twist at the waist while holding the client
- D. Ask for assistance from another staff member
Correct Answer: A
Rationale: The correct technique for transferring a client from a bed to a chair to avoid back injuries is to bend at the knees while maintaining a wide stance and a straight back. This position ensures that the nurse uses leg muscles rather than the back muscles for lifting, reducing the risk of injury. Placing the client's hands on the nurse's shoulders and the nurse's hands under the client's axillae provides additional support and stability during the transfer. Using a mechanical lift may be appropriate for certain situations but is not necessary for a simple bed-to-chair transfer. Twisting at the waist while holding the client can lead to back strain or injury. Asking for assistance from another staff member is a good practice, but proper body mechanics should still be followed to ensure safe client handling.
The patient has undergone surgery for a broken leg and has a cast in place. What should the nurse do to prevent skin impairment?
- A. Assess surfaces exposed to the edges of the cast for pressure areas.
- B. Keep the patient's blood pressure low to prevent overperfusion of tissue.
- C. Allow turning in bed to prevent complications.
- D. Encourage the patient's dietary intake to maintain hydration.
Correct Answer: A
Rationale: To prevent skin impairment in a patient with a cast, the nurse should assess surfaces exposed to the edges of the cast for pressure areas. This is important to prevent pressure ulcers or skin breakdown. Keeping the patient's blood pressure low (Choice B) is not directly related to preventing skin impairment in this scenario. Allowing turning in bed (Choice C) is essential for preventing complications like pressure ulcers and is not contraindicated. Encouraging the patient's dietary intake (Choice D) to maintain hydration is not directly related to preventing skin impairment associated with a cast.
A nurse is collecting data from an older adult client as part of a neurologic examination. Which of the following findings should the nurse expect as changes associated with aging?
- A. Slower light touch sensation
- B. Some vision and hearing decline
- C. Slower fine finger movement
- D. Some short-term memory decline
Correct Answer: B
Rationale: As individuals age, it is common to experience changes in vision and hearing, leading to some decline in these senses. Slower light touch sensation and slower fine finger movement are also typical findings associated with aging. However, some short-term memory decline is more closely related to cognitive aging rather than typical age-related changes in the neurologic system. Therefore, the correct answer is the decline in vision and hearing. Decreased risk of depression is not a typical finding in aging; in fact, the risk of depression may increase as individuals age.
When ambulating a frail, older adult client, the nurse should:
- A. Use the transfer belt if the client is unsteady
- B. Walk beside the client without support
- C. Encourage the client to use a walker
- D. Hold the client's arm for support
Correct Answer: A
Rationale: Using a transfer belt if the client is unsteady is essential to provide added safety and support during ambulation. This device helps the nurse assist the client in maintaining balance and prevents falls. Walking beside the client without support (choice B) may not offer enough assistance for a frail, older adult who is unsteady. Encouraging the client to use a walker (choice C) could be helpful in some cases, but if the client is unsteady during ambulation, additional support like a transfer belt is more appropriate. Holding the client's arm for support (choice D) may not provide enough stability and safety compared to using a transfer belt.