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The nurse is caring for a client with a history of Addison’s disease.
- A. Which laboratory finding is most concerning for a client with Addison’s disease?
- B. Serum sodium of 128 mEq/L.
- C. Serum cortisol of 10 µg/dL.
- D. Blood glucose of 90 mg/dL.
- E. Serum potassium of 4.0 mEq/L.
Correct Answer: A
Rationale: A serum sodium of 128 mEq/L indicates hyponatremia, a life-threatening complication in Addison’s disease due to aldosterone deficiency, risking shock. Low cortisol is expected, and normal glucose and potassium are unremarkable.
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A client has an order for D5NS 1,000 mL to infuse over 8 hours. The IV set delivers 10 drops per mL. The nurse should maintain the infusion rate at:
- A. 10 drops per minute
- B. 15 drops per minute
- C. 21 drops per minute
- D. 32 drops per minute
Correct Answer: C
Rationale: Calculate: 1,000 mL / 8 hours = 125 mL/hour. 125 mL/hour × 10 drops/mL ÷ 60 minutes = 20.83 drops/minute, rounded to 21 drops/minute.
An elderly client with glaucoma is scheduled for an exploratory laparotomy. Which of the following pre-op medications should be questioned?
- A. Demerol (meperidine)
- B. Atropine (atropine)
- C. Tagamet (cimetadine)
- D. Polycillin (ampicillin)
Correct Answer: B
Rationale: Atropine is contraindicated in glaucoma as it can increase intraocular pressure. Demerol , Tagamet , and Polycillin are generally safe in this context.
A client on suicide precautions is verbalizing other options besides suicide, appears to be responding to antidepressant medication, is sleeping and eating better, and has indicated a willingness to interact more with family members.
Based on this data, which of the following nursing actions is MOST appropriate?
- A. Recommend that the physician decrease the client's medication dosage.
- B. Recommend that the treatment team reevaluate the client's treatment plan.
- C. Give the client privileges to walk around the hospital by himself.
- D. Ask the family to begin planning for the client's discharge.
Correct Answer: B
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) may reverse the client's progress (2) correct-data suggests that client is beginning to benefit from treatment; entire treatment team should share data and make a decision about the suicide precautions so that restrictions are changed gradually based on a full-data picture (3) may be the team's decision, but not until a thorough review of the case is completed (4) premature
The LPN/LVN is making assignments in a long-term care facility. Staff on duty include another LPN and a new certified nursing assistant. Which client can most safely be assigned to the nursing assistant?
- A. Ms. A., 92 years old, has dementia and advancing congestive heart failure (CHF).
- B. Ms. B., 83 years old, has Alzheimer's and Parkinson's and is ambulatory with assistance.
- C. Mr. C., 76 years old, has just been transferred from an acute care facility where he had a total hip replacement four days ago.
- D. Mr. D., 29 years old, had a closed head injury and is in a semi-vegetative state with a tracheostomy and a gastrostomy.
Correct Answer: B
Rationale: Ms. B's ambulatory status with assistance aligns with CNA tasks like hygiene and transfers, safest for a new CNA compared to complex needs.
A client has severe second- and third-degree burns over 75% of his body.
The nurse would be MOST concerned if which of the following was observed?
- A. Epigastric pain.
- B. Restlessness.
- C. Tachypnea.
- D. Lethargy.
Correct Answer: C
Rationale: Strategy: Determine how each answer relates to burns. (1) insignificant for burn client (2) may be due to pain (3) correct-body responds to early hypovolemic shock by adrenergic stimulation; vasoconstriction compensates for the loss of fluid, resulting in cool clammy skin, tachycardia, tachypnea, and pale color (4) may be due to pain