Nokea
The healthcare provider prescribes potassium chloride 25 mEq in 500 ml D5W to infuse over 6 hours. The available 20 ml vial of potassium chloride is labeled '10 mEq/5 ml.' How many ml of potassium chloride should the nurse add to the IV fluid?
- A. 12.5
- B. 5
- C. 10
- D. 20
Correct Answer: B
Rationale: To prepare 25 mEq of potassium chloride for the infusion, the nurse should add 5 ml of the 10 mEq/5 ml solution. This concentration provides the required amount of potassium chloride without exceeding the needed volume. Choice A would result in 12.5 mEq, which exceeds the prescribed amount. Choices C and D are incorrect as they do not align with the correct calculation based on the vial concentration.
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While a patient is receiving beta-1b interferon every other day for multiple sclerosis, which serum laboratory test findings should the nurse monitor to assess for possible bone marrow suppression caused by the medication? (Select all that apply)
- A. Platelet count
- B. White blood cell count (WBC)
- C. Sodium and potassium
- D. Red blood cell count (RBC)
Correct Answer: A
Rationale: Beta-1b interferon can lead to bone marrow suppression, impacting blood cell production. Therefore, monitoring the platelet count, white blood cell count (WBC), and red blood cell count (RBC) is essential. Platelet count is a direct indicator of bone marrow function and can show early signs of bone marrow suppression. While sodium, potassium, and albumin/protein levels are important for overall health assessment, they are not directly associated with bone marrow suppression caused by the medication.
A client with complaints of shortness of breath and abdominal pain 1 week after bariatric surgery is admitted for follow-up evaluation. Which assessment finding warrants immediate intervention by the nurse?
- A. Rectal temperature of 101°F
- B. Complaints of left shoulder pain
- C. Blood pressure of 88/50 mmHg
- D. Sustained sinus tachycardia
Correct Answer: C
Rationale: A blood pressure of 88/50 mmHg indicates possible hypovolemia or shock, which requires immediate attention. Hypotension can be a sign of decreased perfusion to vital organs, potentially leading to organ failure. The other options, such as a rectal temperature of 101°F, complaints of left shoulder pain, or sustained sinus tachycardia, while important, do not present the same level of immediate threat to the client's well-being as a critically low blood pressure.
A 3-year-old boy was successfully toilet trained prior to his admission to the hospital for injuries sustained from a fall. His parents are very concerned that the child has regressed in his toileting behaviors. Which information should the nurse provide to the parents?
- A. Children usually resume their toileting behaviors when they leave the hospital
- B. A retraining program will need to be initiated when the child returns home
- C. Diapering will be provided since hospitalization is stressful to preschoolers
- D. A potty chair should be brought from home so he can maintain his toileting skills
Correct Answer: A
Rationale: Children often regress in toileting behaviors during hospitalization due to stress and changes in routine. However, they usually resume normal behaviors once they are discharged and back in their familiar environment. Providing reassurance to the parents that the child is likely to return to his previous toileting habits after leaving the hospital can help alleviate their concerns. Choices B, C, and D are incorrect because they do not address the normal pattern of behavior regression and recovery in toileting skills associated with hospitalization.
Which intervention should the nurse include in a long-term plan of care for a client with Chronic Obstructive Pulmonary Disease (COPD)?
- A. Reduce risk factors for infection
- B. Administer high-flow oxygen during sleep
- C. Limit fluid intake to reduce secretions
- D. Use diaphragmatic breathing to achieve better exhalation
Correct Answer: D
Rationale: The correct answer is D. Diaphragmatic breathing is a beneficial intervention for clients with COPD as it helps improve breathing efficiency and manage symptoms by promoting better air exchange in the lungs. It aids in achieving better exhalation, reducing air trapping, and enhancing overall lung function. Choices A, B, and C are incorrect. While reducing risk factors for infection is important for overall health, it is not a specific long-term intervention for COPD. Administering high-flow oxygen during sleep may be necessary in some cases but is not typically a long-term strategy for managing COPD. Limiting fluid intake to reduce secretions is not recommended as hydration is essential for individuals with COPD to maintain optimal respiratory function and prevent complications like mucus plugs.
What actions should the nurse take regarding an older adult male who had an abdominal cholecystectomy and has become increasingly confused and disoriented over the past 24 hours, found wandering into another client's room and returned to his own room by the unlicensed assistive personnel (UAP)? (Select all that apply)
- A. Apply soft upper limb restraints and raise all four bed rails
- B. Report mental status change to the healthcare provider
- C. Assess the client's breath sounds and oxygen saturation
- D. Assign the UAP to re-assess the client's risk for falls
Correct Answer: B
Rationale: In this situation, the appropriate action for the nurse to take is to report the mental status change to the healthcare provider. Confusion and disorientation post-surgery can be indicative of various factors, such as electrolyte imbalances or respiratory issues, necessitating comprehensive assessment by the healthcare team. Applying restraints and raising bed rails may not address the underlying cause of the confusion, and assigning the UAP to reassess the client's risk for falls does not directly address the cognitive changes observed.