Nokea
The healthcare provider is assessing a client who has a nasogastric tube to low intermittent suction. Which finding indicates that the client may have developed hypokalemia?
- A. Muscle weakness and cramps.
- B. Nausea and vomiting.
- C. Constipation.
- D. Increased blood pressure.
Correct Answer: A
Rationale: Muscle weakness and cramps are characteristic signs of hypokalemia, a condition marked by low levels of potassium in the blood. Potassium is essential for proper muscle function, and its deficiency can lead to muscle weakness and cramps. In the context of a client with a nasogastric tube to low intermittent suction, the loss of potassium through suctioning can contribute to the development of hypokalemia. Nausea and vomiting (choice B) are more commonly associated with gastrointestinal issues rather than hypokalemia. Constipation (choice C) is not a typical finding of hypokalemia; instead, it can be a sign of other gastrointestinal problems. Increased blood pressure (choice D) is not a direct manifestation of hypokalemia; in fact, low potassium levels are more commonly associated with decreased blood pressure.
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A client with chronic renal failure is scheduled for hemodialysis in the morning. Which pre-dialysis medication should the nurse withhold until after the dialysis treatment is completed?
- A. Calcium carbonate (Os-Cal)
- B. Furosemide (Lasix)
- C. Spironolactone (Aldactone)
- D. Multivitamins
Correct Answer: B
Rationale: The correct answer is B: Furosemide (Lasix). Furosemide is a diuretic that promotes fluid loss, and giving it before hemodialysis can lead to excessive fluid loss during the treatment, potentially causing hypovolemia. Withholding furosemide until after the dialysis session helps in preventing this complication. Choices A, C, and D are incorrect because calcium carbonate, spironolactone, and multivitamins are not typically contraindicated before hemodialysis in clients with chronic renal failure.
The nurse is developing a series of childbirth preparation classes for primigravida women and their significant others. What is the priority expected outcome for these classes?
- A. Participants can identify at least three coping strategies to use during labor.
- B. Participants can list signs of labor and when to come to the hospital.
- C. Participants can describe three pain relief measures to use during labor.
- D. Participants can perform three relaxation techniques to use during labor.
Correct Answer: A
Rationale: The priority expected outcome for childbirth preparation classes is for participants to be able to identify coping strategies to use during labor. This is crucial as coping strategies can help women manage pain, stress, and anxiety during childbirth. Choice B is important but does not focus on coping strategies needed during labor. Choice C is relevant but focuses solely on pain relief measures which are a part of coping strategies. Choice D is also relevant but does not encompass all aspects of coping with labor effectively.
A client with a history of peptic ulcer disease is admitted with severe abdominal pain. Which assessment finding requires immediate intervention?
- A. Epigastric tenderness.
- B. Bowel sounds are hypoactive.
- C. The client reports sudden, severe abdominal pain.
- D. Bowel sounds are hyperactive.
Correct Answer: C
Rationale: The correct answer is C. Sudden, severe abdominal pain can indicate a perforated ulcer, which is a medical emergency requiring immediate intervention. Epigastric tenderness (choice A) may be expected in a client with peptic ulcer disease but does not necessarily require immediate intervention. Hypoactive bowel sounds (choice B) are concerning but not as urgent as sudden, severe abdominal pain. Hyperactive bowel sounds (choice D) are more indicative of conditions like gastroenteritis rather than a perforated ulcer, making it a less critical finding compared to sudden, severe abdominal pain.
During a home visit, the nurse observes that a client with limited mobility has difficulty preparing meals. What should the nurse do first?
- A. suggest that the client use a meal delivery service
- B. assist the client in meal planning
- C. refer the client to a dietitian
- D. educate the client on easy-to-prepare healthy meals
Correct Answer: B
Rationale: Assisting the client in meal planning is the most appropriate initial action as it addresses the immediate issue of meal preparation. By helping the client plan meals according to their dietary needs and limitations, the nurse can support the client in maintaining a healthy diet despite limited mobility. While suggesting a meal delivery service (Choice A) may be a viable option, assisting in meal planning allows for more personalized and sustainable solutions. Referring the client to a dietitian (Choice C) may be necessary for specialized nutritional advice but is not the first step in addressing the immediate concern. Educating the client on easy-to-prepare healthy meals (Choice D) could be beneficial, but meal planning is a more comprehensive approach to ensure the client's dietary needs are met consistently.
A client with a history of myocardial infarction is prescribed aspirin therapy. Which instruction should the nurse include in the client's teaching plan?
- A. Take aspirin with food.
- B. Take aspirin at the same time every day.
- C. Avoid taking aspirin with alcohol.
- D. Discontinue aspirin if you experience ringing in your ears.
Correct Answer: C
Rationale: The correct instruction for the nurse to include in the client's teaching plan is to avoid taking aspirin with alcohol. Combining aspirin with alcohol can increase the risk of gastrointestinal bleeding and other complications. Taking aspirin with food helps reduce stomach upset, but it is not the most crucial instruction in this scenario. While taking aspirin at the same time every day can help with consistency, it is not as critical as avoiding alcohol. Discontinuing aspirin if experiencing ringing in the ears is important to address potential side effects, but it is not directly related to preventing complications when combining with alcohol.