Nokea
The nurse is caring for a client with a history of Addison’s disease. Which finding indicates a potential adrenal crisis?
- A. Blood pressure of 90/60 mmHg
- B. Weight gain of 2 pounds
- C. Serum sodium of 140 mEq/L
- D. Heart rate of 80 beats per minute
Correct Answer: A
Rationale: Adrenal crisis in Addison’s disease causes hypotension (e.g., 90/60 mmHg) due to cortisol and aldosterone deficiency, leading to shock. Weight gain, normal sodium, and normal heart rate are not indicative.
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Nursing care for the substance abuse client experiencing alcohol withdrawal delirium includes:
- A. Maintaining seizure precautions
- B. Restricting fluid intake
- C. Increasing sensory stimuli
- D. Applying ankle and wrist restraints
Correct Answer: A
Rationale: These clients are at high risk for seizures during the 1st week after cessation of alcohol intake. Fluid intake should be increased to prevent dehydration. Environmental stimuli should be decreased to prevent precipitation of seizures. Application of restraints may cause the client to increase his or her physical activity and may eventually lead to exhaustion.
A client with pregnancy-induced hypertension is scheduled for a C-section. Before surgery, the nurse should keep the client:
- A. On her right side
- B. Supine with a small pillow
- C. On her left side
- D. In knee chest position
Correct Answer: C
Rationale: The left lateral position improves uteroplacental blood flow in pregnancy-induced hypertension, reducing fetal distress risk. Right-sided, supine, or knee-chest positions are less optimal.
The nurse is caring for an adolescent with a five-year history of bulimia. A common clinical finding in the client with bulimia is:
- A. Extreme weight loss
- B. Dental caries
- C. Hair loss
- D. Decreased temperature
Correct Answer: B
Rationale: Frequent vomiting in bulimia exposes teeth to stomach acid, leading to dental caries (tooth decay), a common clinical finding.
A physician's order reads: Administer KCl 10% oral solution 1.5 mL. The KCl bottle reads 20 mEq/15 mL. What dosage should the nurse administer to the infant?
- A. 1 mEq
- B. 1.13 mEq
- C. 2 mEq
- D. 3 mEq
Correct Answer: C
Rationale: 1.33 mEq = 1 mL, then 1.5 mL X = 1.99, or 2 mEq.
A client with a history of a heart failure is receiving Furosemide (Lasix). The nurse should monitor the client for:
- A. Hypokalemia
- B. Hyperglycemia
- C. Hypertension
- D. Weight gain
Correct Answer: A
Rationale: Furosemide, a loop diuretic, causes potassium loss, risking hypokalemia, requiring monitoring. Hyperglycemia, hypertension, and weight gain are not primary concerns.