Nokea
The nurse is caring for a client in the medical-surgical unit. The nurse is reviewing the client's laboratory data and should take which action.
- A. Review the client's current medications
- B. Plan to initiate daily fluid restrictions
- C. Clarify the prescribed chest radiograph (x-ray)
- D. Insert an indwelling urinary catheter to monitor urinary output
Correct Answer: A
Rationale: Reviewing medications identifies potential causes of lab abnormalities, guiding appropriate interventions.
You may also like to solve these questions
The nurse is teaching a group of students about fluids and electrolytes. It would be correct for the nurse to state that the role of calcium is to Select all that apply.
- A. promote blood clotting.
- B. increase bone density.
- C. promote healthy dentition.
- D. regulate fluid balance.
- E. maintain neuromuscular health.
Correct Answer: A,B,C,E
Rationale: Calcium promotes blood clotting, bone density, dentition, and neuromuscular function, but does not directly regulate fluid balance.
The nurse cares for a client with a potassium of 3.2 mEq/L (mmol/L) [3.5-5 mEq/L, mmol/L]. Which of the following medications may cause this abnormality?
- A. spironolactone
- B. triamterene
- C. prednisone
- D. lisinopril
Correct Answer: B
Rationale: Triamterene is a potassium-sparing diuretic that can cause hypokalemia by reducing potassium excretion. Spironolactone (A) also spares potassium but is less likely to cause hypokalemia. Prednisone (C) primarily affects glucose and sodium, not potassium. Lisinopril (D) may cause hyperkalemia, not hypokalemia.
The nurse is teaching a client about the newly prescribed medication, sevelamer. Which statement, if made by the client, would indicate a correct understanding of the teaching?
- A. My blood pressure may increase while I take this medication.
- B. This medication will help lower my calcium level.
- C. I should take this medication with my meal.
- D. I may experience bad diarrhea with this medication.
Correct Answer: C
Rationale: Sevelamer is taken with meals to bind dietary phosphate, reducing serum phosphorus. It does not affect blood pressure (D), lower calcium (A), or typically cause diarrhea (B).
Following surgery for a prolapsed bladder, a 74-year-old female client is two days postoperative with an indwelling urinary catheter. While the nurse is making morning rounds, the client states, 'I feel like peeing again!' The most appropriate response for the nurse is:
- A. It's just bladder spasms. Nothing to worry about.'
- B. Let me look at your urine bag to ensure it's draining properly.'
- C. You should do Kegel exercises regularly to stop this urge to void.'
- D. Is this the first time this has happened?'
Correct Answer: B
Rationale: Checking the urine bag ensures the catheter is draining properly, addressing the sensation of needing to urinate.
The nurse cares for a client with a potassium of 5.7 mEq/L (mmol/L) [3.5-5 mEq/L, mmol/L]. The nurse understands that this potassium level may be caused by Select all that apply.
- A. Cushing's disease.
- B. nasogastric tube suctioning.
- C. salt substitutes.
- D. hyperinsulinism.
- E. adrenal insufficiency.
Correct Answer: C,E
Rationale: Salt substitutes (potassium-based) and adrenal insufficiency (reduced aldosterone) cause hyperkalemia.