Nokea
The nurse is caring for a client with a history of alcoholism.
- A. Which laboratory finding is most concerning for a client with chronic alcoholism?
- B. Serum potassium of 3.2 mEq/L.
- C. Blood urea nitrogen of 18 mg/dL.
- D. Hemoglobin of 13.5 g/dL.
- E. Aspartate aminotransferase (AST) of 150 U/L.
Correct Answer: A
Rationale: A serum potassium of 3.2 mEq/L indicates hypokalemia, a life-threatening complication in chronic alcoholism due to poor nutrition and diuretic effects of alcohol, risking arrhythmias. Elevated AST reflects liver damage, but hypokalemia is more immediately dangerous.
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The nurse is caring for a man who has chronic emphysema and is receiving oxygen at 2 L/min. The nurse enters the room to find that his wife has turned the oxygen up to 10 L/min because her husband is having increasing difficulty breathing. What is the best immediate action for the nurse to take?
- A. Explain to the wife that his oxygen was ordered at 2 L/min and it should stay there until the physician orders something else
- B. Turn the oxygen setting back to 2 L/min
- C. Tell the wife that 10 L/min is too high and turn it back to 5 L/min
- D. Assure her that 10 L/min will ease her husband's breathing
Correct Answer: B
Rationale: High oxygen in emphysema can suppress respiratory drive, worsening hypercapnia; returning to 2 L/min is critical, followed by physician consultation.
Two days after admission, a client's sputum culture is reported as positive for tuberculosis.
While awaiting orders from the physician, the nurse should
- A. initiate measures to transfer the client to a tuberculosis unit.
- B. institute measures to initiate airborne precautions.
- C. arrange for all of the client's personal effects to be decontaminated.
- D. notify the client's family that they have been exposed to a contagious disease.
Correct Answer: B
Rationale: Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) this action is unnecessary at this time, and if indicated, the physician will write appropriate transfer orders (2) correct-clients with tuberculosis are placed on airborne precautions in the hospital, and the nurse should begin preparations for this immediately (3) personal effects do not have to be decontaminated (4) it is the physician's job to tell the family when indicated
A pre-term newborn is to be fed breast milk through nasogastric tube. Breast milk is preferred over formula for premature infants because it
- A. Contains less lactose
- B. Is higher in calories/ounce
- C. Provides antibodies
- D. Has less fatty acid
Correct Answer: C
Rationale: Provides antibodies. Breast milk offers maternal antibodies, enhancing immunity in preterm infants.
An infant who had a repair of a cleft lip and palate. The respiratory assessment reveals that the infant has upper airway congestion and slightly labored respirations.
Which of the following nursing actions would be MOST appropriate?
- A. Elevate the head of the bed.
- B. Suction the infant's mouth and nose.
- C. Position the infant on one side.
- D. Administer oxygen until breathing is easier.
Correct Answer: C
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) will not promote adequate drainage from the upper airways (2) contraindicated based on the infant's operative site (3) correct, will facilitate drainage of mucus from upper airway, and will promote adjustment to breathing through the nose (4) does not relieve the congestion
A disoriented male client reveals that the client has a self-care deficit (feeding).
Which of the following would indicate to the nurse that the client has made a positive response to the plan of care?
- A. Client explains the relationship between weight loss and change in mental status.
- B. Client identifies the basic four food groups.
- C. Client states he needs to drink more water.
- D. Client feeds self when the nurse stays with him and cues him.
Correct Answer: D
Rationale: Strategy: Determine the outcome of each answer choice. (1) would not be realistic in a client who is disoriented (2) would not be realistic in a client who is disoriented (3) would not be realistic in a client who is disoriented (4) correct-disoriented client who is not able to be an independent self-care agent will need cuing from the nurse to accomplish self-feeding