Nokea
The nurse cares for a client and receives a phone call from the laboratory department regarding a critical sodium level of 122 mEq/L (mmol/L) [135-145 mEq/L, mmol/L]. The nurse should take which initial action?
- A. Notify the primary healthcare provider (PHCP)
- B. Implement seizure precautions
- C. Read back the result for verification
- D. Recollect the laboratory specimen
Correct Answer: C
Rationale: Reading back the critical result verifies accuracy, the first step before further action. Notifying the provider, seizure precautions, or recollecting follow verification.
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The nurse is working with a group of students and a student asks what cyanosis means. What is the nurse's best response?
- A. Cyanosis is a condition characterized by a yellowish discoloration of the skin and mucous membranes due to excessive oxygenation.
- B. Cyanosis is the blue coloring of the skin and mucous membranes in the presence of poorly oxygenated blood.
- C. Cyanosis is the primary indication that the client has pneumonia.
- D. Cyanosis is the bluish discoloration of the skin and mucous membranes due to poor peripheral circulation, even in the presence of normal oxygen levels.
Correct Answer: B
Rationale: Cyanosis is blue discoloration due to poorly oxygenated blood. Yellowish discoloration is jaundice, it’s not specific to pneumonia, and circulation issues alone don’t cause it if oxygen is normal.
The nurse cares for a client scheduled for spinal surgery in one hour. The nurse anticipates that the primary healthcare provider (PHCP) will prescribe
- A. gentamicin
- B. enoxaparin
- C. hydromorphone
- D. cyclobenzaprine
Correct Answer: B
Rationale: Enoxaparin, a low-molecular-weight heparin, is commonly prescribed preoperatively for spinal surgery to prevent venous thromboembolism due to prolonged immobility. Gentamicin is an antibiotic, hydromorphone is for pain, and cyclobenzaprine is a muscle relaxant, none of which are typically prioritized preoperatively for this purpose.
The nurse is teaching at an interdisciplinary conference focused on age-related changes. Which of the following are expected in the older adult? Select all that apply.
- A. Fatty tissue is redistributed
- B. Skin becomes less elastic
- C. Cardiac output increases
- D. Muscle mass increases
- E. Hormone production increases
- F. Visual and hearing acuity diminishes
Correct Answer: A,B,F
Rationale: Aging involves fat redistribution, less elastic skin, and diminished sensory acuity. Cardiac output, muscle mass, and hormone production decrease.
The nurse needs to assess the use of complementary and alternative medicine (CAM) because:
- A. Patients should be warned that most CAM therapies are potentially dangerous
- B. Additional treatment may not be needed if the patient is using CAM
- C. CAM therapy could interact with prescription and over-the-counter medications
- D. Most CAM therapies are essentially ineffective
Correct Answer: C
Rationale: CAM therapies can interact with medications, affecting efficacy or safety. Not all CAM is dangerous, ineffective, or a replacement for conventional treatment.
The nurse is discussing infection control with a group of nursing students. Which conditions would it be correct to state droplet precautions are used for? Select all that apply.
- A. Influenza
- B. Viral meningitis
- C. Pertussis
- D. Hepatitis C
- E. Lyme disease
Correct Answer: A,C
Rationale: Influenza and pertussis require droplet precautions due to respiratory transmission. Viral meningitis, hepatitis C, and Lyme disease do not.