Nokea
The nurse cares for a client who is pale and frequently reports fatigue, weakness, and dizziness. Which serum laboratory test result is the nurse's priority for planning care?
- A. Hematocrit 43% (0.43)
- B. Sodium 130 mEq/L (130 mmol/L)
- C. Potassium 4.8 mEq/L (4.8 mmol/L)
- D. Hemoglobin of 7 g/dL (70 mmol/L)
Correct Answer: D
Rationale: The client's hemoglobin level and sodium level are low; however, the nurse uses the hemoglobin results to plan care because the client's clinical indicators are consistent with anemia. The client is pale because the serum hemoglobin is low; thus, the client's tissues are perfused with blood that has a low oxygen-carrying capacity. The client is weak and dizzy because the blood does not carry enough oxygen to meet tissue oxygen demands. The normal sodium level is 135 to 145 mEq/L (135 to 145 mmol/L). Although a client who is hyponatremic can also feel weak and dizzy, a hyponatremic client is unlikely to be pale. The hematocrit and the potassium levels are within normal limits.
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A therapeutic milieu is:
- A. A safe environment of care that is conducive to the prevention of medical errors.
- B. A client care area that provides personal privacy and the confidentiality of medical information.
- C. A European method of design and color to promote health and wellness.
- D. The provision of a therapeutic environment of consistency to promote health.
Correct Answer: D
Rationale: A therapeutic milieu is a structured environment designed to promote healing and recovery through consistency, safety, and therapeutic interactions.
After a lobectomy for lung cancer, the nurse instructs the client to perform deep-breathing exercises to:
- A. Decrease blood flow to the lungs for rest and increased surface alveoli ventilation.
- B. Elevate the diaphragm to enlarge the thorax so that the lung surface area available for gas exchange is increased.
- C. Control the rate of air flow to the remaining lobe to decrease the risk of hyperinflation.
- D. Expand the alveoli and increase lung surface available for ventilation.
Correct Answer: D
Rationale: Deep-breathing exercises expand alveoli, increasing lung surface area for ventilation post-lobectomy.
The nurse is caring for a client with a chest tube. Which of the following findings requires immediate intervention?
- A. Continuous bubbling in the water seal chamber.
- B. Tubing clamped near the insertion site.
- C. Chest tube secured to the chest wall.
- D. Suction set at 20 cm H2O.
Correct Answer: B
Rationale: Clamping the tubing near the insertion site can cause a tension pneumothorax, requiring immediate correction.
A nurse is having difficulty establishing a relationship with an aggressive client. What strategy will most likely improve the relationship?
- A. The nurse and the client agree to work to improve their involvement in the therapeutic relationship.
- B. The nurse establishes goals for having only positive interactions with the client.
- C. The nurse agrees to be submissive so the client can dominate the relationship.
- D. The nurse seeks assistance from colleagues to become more aware of the quality of the interactions and more sensitive to the dynamics of communication.
Correct Answer: D
Rationale: Seeking colleague assistance enhances self-awareness and communication skills, improving the therapeutic relationship with an aggressive client.
The nurse is caring for a client with bipolar disorder in a manic phase. Which intervention is most appropriate?
- A. Encourage group activities.
- B. Provide a quiet environment.
- C. Allow unlimited phone calls.
- D. Offer high-calorie snacks.
Correct Answer: B
Rationale: A quiet environment reduces stimuli, helping to calm a client in a manic phase.