Nokea
The nurse assesses that a client who is disoriented drank eight glasses of water in two hours and is continuing to drink excessive amounts of water. Because the nurse is concerned about water intoxication, which laboratory value should the nurse monitor?
- A. White blood cell count.
- B. Serum sodium levels.
- C. Serum potassium levels.
- D. Creatinine clearance.
Correct Answer: B
Rationale: Excess water dilutes sodium, risking hyponatremia.
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To assess a client's dorsalis pedis pulse, the nurse applies firm pressure over the top of the foot between the extension tendons of the great and first toes, but does not feel a pulsation. Which action should the nurse take next?
- A. Reduce the amount of pressure being applied on the top of the foot.
- B. Palpate the site on the inner side of the ankle below the medial malleolus.
- C. Obtain a doppler stethoscope to auscultate the pulse at the same site.
- D. Document in the nurses' notes that the dorsalis pedis pulse is not palpable.
Correct Answer: A
Rationale: Reducing pressure may reveal the pulse.
The nurse retrieves hydromorphone 4 mg/mL from an automated dispensing system, for a client who is receiving hydromorphone 3 mg IM every 6 hours PRN for severe pain. How many mL should the nurse administer to the client? (Enter the numerical value only. If rounding is required, round to the nearest tenth.)
Correct Answer: 0.8
Rationale: 3 mg ÷ 4 mg/mL = 0.75 mL, rounded to 0.8 mL.
History and physical
The client is a 69-year-old male with a history of emphysema and hypertension. He presented to the emergency room with shortness of breath and reporting chest pain. He was admitted to the medical floor for cardiac exam and monitoring.
Nurses notes :
1930
The client was alert and oriented when he first came on the unit. Now the client is confused and asking where he is at. His oxygen mask was found on the floor. His lips are blue.
Vital signs
. Heart rate 100 beats/minute
Respiratory rate 29 breaths/minute
. Blood pressure 155/89 mm Hg
Oxygen saturation 75% on room air
Orders:
1845
Admit to medical floor
. Clear liquid diet
12-lead electrocardiogram (ECG)
Apply oxygen 10 L/minute non-rebreather, titrate to keep oxygen saturation greater than 88%
.Send specimens to the laboratory for a blood gas, cardiac enzymes, chemistry, and complete blood count.
Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.
- A. Replace the non rebreather mask;Perform oropharyngeal suctioning;Change the oxygen delivery method;Increase the flow of oxygen to 12L;Use a manual resuscitation bag to provide breaths
- B. Obstructed airway;Hypoxia;Pulmonary edema;Apnea
- C. Color and consistency of mucus;Oxygen saturation;Level of consciousness;Skin color;Gag reflex
Correct Answer:
Rationale: Hypoxia: The client's symptoms of confusion, blue lips (cyanosis), and a low oxygen saturation of 75% on room air indicate severe hypoxia, which requires immediate intervention to restore adequate oxygenation.
Replace the non-rebreather mask: This action ensures that the client receives the prescribed oxygen therapy at the correct flow rate, which is critical for increasing oxygen levels in the blood.
Increase the flow of oxygen to 12 L: Adjusting the oxygen flow rate to the prescribed level is necessary to effectively increase the client's oxygen saturation and relieve hypoxia.
Oxygen saturation: Monitoring oxygen saturation is essential to assess the effectiveness of the oxygen therapy and ensure that the client's oxygen levels are being maintained above 88%, as per the orders.
Level of consciousness: Monitoring the client’s level of consciousness helps evaluate the impact of hypoxia on the brain and determines whether the interventions are improving the client's neurological status.
An older adult client is admitted to the medical unit following a fall at home. While undressing the client, the nurse observes that the client is wearing an adult diaper and skin breakdown is obvious over the sacral area. Which action should the nurse implement first?
- A. Apply a barrier ointment to intact areas that may be exposed to moisture.
- B. Determine the size and depth of skin breakdown over the sacral area.
- C. Complete a functional assessment of the client's self-care abilities.
- D. Establish a toileting schedule to decrease episodes of incontinence.
Correct Answer: B
Rationale: Assessing breakdown severity guides treatment planning.
The nurse is teaching a spouse how to care for a client who recently had a stroke and has residual weakness on the right side. Which style shoes should the nurse recommend the client wear when ambulating with the spouse's assistance?
- A. Tennis shoes with velcro.
- B. Rubber-soled slippers.
- C. Slip-on rubber shower shoes.
- D. Leather-soled loafers.
Correct Answer: A
Rationale: Velcro tennis shoes provide support and stability.