Nokea
Laboratory Reference Ranges
Sodium
136-145 mEq/L
(136-145 mmol/L)
The medical-surgical nurse cares for a group of clients. Which client situations would prompt the nurse to notify the health care provider during the middle of the night? Select all that apply.
- A. Client develops right-sided upper and lower extremity drift
- B. Client found lying unconscious on the floor
- C. Client has order for heparin with surgery planned for the morning
- D. Client has serum sodium of 124 mEq/L (124 mmol/L)
- E. Client refuses a prescribed, routine pain medication
Correct Answer: A,B,C,D
Rationale: Extremity drift (A), unconsciousness (B), heparin before surgery (C), and severe hyponatremia (D) are urgent and require notification. Refusing pain medication (E) is not critical.
You may also like to solve these questions
The nurse is caring for a client with a tracheostomy who has an order to begin oral intake. Which of the following actions should the nurse take to decrease the client's risk for aspiration?
- A. Fully inflate the tracheostomy cuff before the client begins to eat.
- B. Encourage the client to use a straw when drinking fluids.
- C. Instruct the client to tilt the head back when swallowing
- D. Provide thickened liquids for the client.
Correct Answer: D
Rationale: Thickened liquids (D) reduce aspiration risk by slowing transit. Inflating the cuff (A) is not always necessary, straws (B) may increase risk, and tilting the head back (C) worsens aspiration.
The clinic nurse is caring for a client who had cataract surgery with intraocular lens implantation 2 days ago. Which client report requires priority intervention?
- A. Blurry vision in the affected eye
- B. Constipation
- C. Itching in the affected eye
- D. Sleeping on 2 pillows at night
Correct Answer: C
Rationale: Itching in the affected eye (C) may indicate infection or complications post-cataract surgery, requiring immediate intervention. Blurry vision (A) is expected initially, constipation (B) is unrelated, and sleeping elevated (D) is appropriate.
A parent tells the nurse that their 6 year-old child who normally enjoys school, has not been doing well since the grandmother died 2 months ago. Which statement most accurately describes thoughts on death and dying at this age?
- A. Death is personified as the bogeyman or devil
- B. Death is perceived as being irreversible
- C. The child feels guilty for the grandmother's death
- D. The child is worried that he, too, might die
Correct Answer: A
Rationale: Death is personified as the bogeyman or devil. Personification of death is typical of this developmental level.
The clinic nurse is reinforcing client teaching about the tiotropium that has been prescribed for chronic obstructive pulmonary disease (COPD). Which statement indicates that the client has a correct understanding of this medication?
- A. A capsule holds the powdered medication that I put in a special inhaler.
- B. I do not need to rinse my mouth out with water after taking tiotropium.
- C. I have been taking tiotropium every time I have difficulty breathing.
- D. Tiotropium helps control my COPD by reducing inflammation in my airway.
Correct Answer: A
Rationale: Tiotropium is a powder in a capsule used with an inhaler (A). Rinsing the mouth (B) is unnecessary, but it's taken daily, not PRN (C), and it's a bronchodilator, not anti-inflammatory (D).
A client diagnosed with heart failure has an 8-hour urine output of 200 mL. What is the nurse's first action?
- A. Auscultate the client's breath sounds
- B. Encourage the client to increase fluid intake
- C. Report the findings to the supervising registered nurse
- D. Start an IV line for diuretic administration
Correct Answer: C
Rationale: Low urine output (200 mL/8 hr) in heart failure suggests worsening fluid retention, requiring immediate reporting to the RN (C). Auscultation (A), fluids (B), and IV diuretics (D) require RN direction.