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The nurse is caring for a client who is receiving a continuous IV infusion of insulin for diabetic ketoacidosis. Which of the following laboratory results should the nurse report immediately?
- A. Blood glucose of 200 mg/dL.
- B. Potassium 3.0 mEq/L.
- C. pH of 7.30.
- D. Sodium 135 mEq/L.
Correct Answer: B
Rationale: Hypokalemia (3.0 mEq/L) risks arrhythmias during insulin therapy for DKA. Options A, C, and D are less urgent.
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A client has returned from having a transurethral prostatectomy. Which finding should be reported to the doctor immediately?
- A. An hourly urinary output of 40-50 mL
- B. Bright red urine with many clots
- C. Dark red urine with few clots
- D. Requests for pain med every 4 hours
Correct Answer: B
Rationale: Bright red urine with many clots indicates significant bleeding post-prostatectomy, requiring immediate reporting. Normal output is 40-50 mL/hour, dark red urine with few clots is expected, and pain med requests are routine.
A client with asthma has low pitched wheezes present on the final half of exhalation. One hour later the client has high pitched wheezes extending throughout exhalation. This change in assessment indicates to the nurse that the client
- A. Has increased airway obstruction
- B. Has improved airway obstruction
- C. Needs to be suctioned
- D. Exhibits hyperventilation
Correct Answer: A
Rationale: Has increased airway obstruction. The higher pitched a sound is, the more narrow the airway. Therefore, the obstruction has increased or worsened.
The nurse is to remove an indwelling urinary catheter from an adult client. Which step should be done first?
- A. Cut the catheter with scissors.
- B. Withdraw the fluid from the balloon.
- C. Clamp the catheter.
- D. Remove the catheter.
Correct Answer: B
Rationale: Withdrawing fluid from the balloon deflates it, allowing safe catheter removal without urethral trauma. Cutting, clamping, or pulling without deflation risks injury.
The nurse is caring for a client with a history of Parkinson’s disease.
- A. Which intervention is most effective for improving mobility in a client with Parkinson’s disease?
- B. Encourage a high-fiber diet.
- C. Administer levodopa on an empty stomach.
- D. Restrict physical activity to prevent falls.
- E. Apply warm compresses to joints.
Correct Answer: B
Rationale: Administering levodopa on an empty stomach enhances absorption, improving motor function in Parkinson’s disease. High-fiber diets prevent constipation, activity is encouraged, and compresses are ineffective for mobility.
The nurse is caring for a client who is receiving IV vancomycin for a methicillin-resistant Staphylococcus aureus (MRSA) infection. Which of the following findings would be of GREATest concern to the nurse?
- A. Blood pressure of 130/80 mmHg.
- B. Heart rate of 88 bpm.
- C. Redness at the IV site.
- D. Urine output of 50 mL/hour.
Correct Answer: C
Rationale: Redness at the IV site suggests phlebitis or infiltration, which can lead to tissue damage or reduced vancomycin delivery, requiring immediate action. Options A, B, and D are normal: blood pressure 130/80 mmHg, heart rate 88 bpm, and urine output 50 mL/hour indicate stability.