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The healthcare provider reviews the laboratory results of a client whose serum pH is 7.38. What does this value imply about the client's homeostasis?
- A. Alkalosis
- B. Acidosis
- C. Normal serum pH
- D. Incompatible with life
Correct Answer: C
Rationale: A pH of 7.38 falls within the normal range (7.35-7.45), indicating that the client's acid-base balance is adequately maintained. Choices A and B are incorrect as alkalosis and acidosis refer to abnormal pH levels. Choice D is incorrect as a pH of 7.38 within the normal range is compatible with life.
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A client with a diagnosis of heart failure is receiving furosemide (Lasix). Which electrolyte imbalance should the nurse monitor for?
- A. Hyperkalemia.
- B. Hyponatremia.
- C. Hypocalcemia.
- D. Hypokalemia.
Correct Answer: D
Rationale: The correct answer is D: Hypokalemia. Furosemide is a loop diuretic that can cause potassium loss, leading to hypokalemia. Therefore, the nurse should monitor the client for low potassium levels. Choice A, Hyperkalemia, is incorrect as furosemide does not typically cause high potassium levels. Choice B, Hyponatremia, is incorrect as furosemide primarily affects potassium levels, not sodium. Choice C, Hypocalcemia, is incorrect as furosemide does not directly impact calcium levels.
What is the most important information for the nurse to provide to a client with a diagnosis of major depressive disorder who is started on a selective serotonin reuptake inhibitor (SSRI)?
- A. Take the medication with food
- B. Avoid foods high in tyramine
- C. Report any thoughts of self-harm immediately
- D. Expect to see improvement within 24 hours
Correct Answer: C
Rationale: The correct answer is C: 'Report any thoughts of self-harm immediately.' When starting an SSRI, clients should be informed to report any thoughts of self-harm promptly. SSRIs can initially increase suicidal ideation, especially in the early stages of treatment. This information is crucial for the client's safety and well-being. Choices A, B, and D are incorrect because taking the medication with food, avoiding foods high in tyramine, and expecting immediate improvement within 24 hours are not the most critical pieces of information for a client starting on an SSRI.
Prior to administering morphine sulfate (Morphine), the nurse takes the client's vital signs. Based on which finding should the nurse withhold administration of the medication until the charge nurse is notified?
- A. Temperature of 100.8°F
- B. A pulse rate of 150 beats per minute
- C. A respiratory rate of 10 breaths per minute
- D. A blood pressure of 180/110
Correct Answer: C
Rationale: The correct answer is C because a low respiratory rate is a critical concern when administering opioids like morphine, as they can suppress breathing. A high pulse rate (choice B) and high blood pressure (choice D) are not immediate contraindications for administering morphine. A slightly elevated temperature (choice A) may not necessarily require withholding morphine.
The nurse is teaching a client about the administration of a subcutaneous injection. Which site is most appropriate for this type of injection?
- A. Deltoid muscle
- B. Dorsogluteal muscle
- C. Ventrogluteal muscle
- D. Abdomen
Correct Answer: D
Rationale: The abdomen is a common site for subcutaneous injections due to its accessibility and ample subcutaneous tissue. Subcutaneous injections are typically given in areas with a layer of fat between the skin and muscle, such as the abdomen, to allow for slow and consistent absorption of the medication. The deltoid muscle is more appropriate for intramuscular injections, not subcutaneous. The dorsogluteal muscle and ventrogluteal muscle are also more suited for intramuscular injections, not subcutaneous.
During a health screening, a client's blood pressure reads 160/100 mm Hg. What should the nurse recommend?
- A. Schedule a follow-up appointment
- B. Start making immediate dietary changes
- C. Begin an exercise program
- D. All of the above
Correct Answer: A
Rationale: A follow-up with a healthcare provider is necessary to assess and manage the newly identified hypertension. While dietary changes and exercise are important for managing high blood pressure, immediate lifestyle modifications without further evaluation by a healthcare provider may not be safe or effective. Option A is the most appropriate initial step to ensure proper assessment and management of the client's blood pressure. Therefore, choices B and C are incorrect in this scenario. Option D is also incorrect because not all options should be implemented without proper medical guidance.