Nokea
The licensed practical nurse is assisting the RN with preparation for administering a transfusion of whole blood. Which action by the nurse predisposes the client to the development of hyperkalemia?
- A. Allowing the blood to warm to room temperature
- B. Administering blood that is 24 hours old
- C. Administering blood with an 18-gauge needle
- D. Filling the drip chamber below the level of the filter
Correct Answer: A
Rationale: Allowing blood to warm to room temperature can cause red blood cells to hemolyze, releasing potassium and increasing the risk of hyperkalemia.
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A client one day after a thoracotomy.
Nursing actions on the care plan include: turn, cough, and deep breathe q2h. The nurse understands that the purpose of this nursing action is to
- A. promote ventilation and prevent respiratory acidosis.
- B. increase oxygenation and removal of secretions.
- C. increase pH and facilitate balance of bicarbonate.
- D. prevent respiratory alkalosis by increasing oxygenation.
Correct Answer: A
Rationale: Strategy: Think about each answer choice. (1) correct-primary purpose of this nursing measure is to improve and/or maintain good gas exchange, especially removal of carbon dioxide in order to prevent respiratory acidosis (2) answer choice #1 is better in that it refers to ventilation rather than oxygenation (3) increasing the pH is not desirable (4) respiratory alkalosis is not prevented by this nursing measure
The nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following laboratory results should the nurse monitor closely?
- A. Serum potassium and glucose.
- B. Serum cholesterol and triglycerides.
- C. Serum calcium and magnesium.
- D. Serum sodium and chloride.
Correct Answer: A
Rationale: TPN can cause hyperglycemia and hypokalemia; monitoring potassium and glucose is critical. Options B, C, and D are less immediately relevant.
A staff member informs the nurse that his six-year-old child has head lice.
It is MOST important for the nurse to take which of the following actions?
- A. Inspect the staff member's head for louse and nits.
- B. Inform the staff member that he cannot care for clients until further notice.
- C. Request that the staff member to contact his physician.
- D. Instruct the staff member about how to use Kwell.
Correct Answer: A
Rationale: Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? Yes. Is there an appropriate assessment? Yes. (1) correct-observe for movement (louse) or small whitish oval specks that adhere to the hair shaft (nits); treat with gamma-benzene hexachloride (Kwell) (2) confirm the presence of lice before excluding from duty; if lice present, exclude from patient care until appropriate treatment has been received and shown to be effective (3) should assess first (4) should assess first, apply shampoo to dry hair and work into lather for 4-5 minutes
The nurse is caring for a client who is postoperative day 1 after a total hysterectomy. Which of the following findings should the nurse report immediately?
- A. Mild pain at the incision site.
- B. Temperature of 100.8°F (38.2°C).
- C. Scant vaginal bleeding.
- D. Urine output of 50 mL/hour.
Correct Answer: B
Rationale: A temperature of 100.8°F suggests infection, a serious post-hysterectomy complication. Options A, C, and D are normal.
Which information should be given to a client taking Dilantin (phenytoin)?
- A. Taking the medication with meals will increase its effectiveness
- B. The medication can cause sleep disturbances
- C. More frequent dental appointments will be needed for special gum care
- D. The medication decreases the effects of oral contraceptives
Correct Answer: C
Rationale: Phenytoin can cause gingival hyperplasia, necessitating more frequent dental visits for gum care.