Nokea
The nurse is caring for a client with a history of atrial fibrillation who is receiving digoxin (Lanoxin) 0.125 mg PO daily. Which of the following laboratory results would be of GREATest concern to the nurse?
- A. Potassium 3.0 mEq/L.
- B. Sodium 140 mEq/L.
- C. Magnesium 2.0 mEq/L.
- D. Calcium 9.0 mg/dL.
Correct Answer: A
Rationale: Hypokalemia (potassium 3.0 mEq/L) increases the risk of digoxin toxicity, which can cause life-threatening arrhythmias in atrial fibrillation. Options B, C, and D are normal: sodium 140 mEq/L, magnesium 2.0 mEq/L, and calcium 9.0 mg/dL do not affect digoxin.
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The client who is scheduled for a knee replacement asks the nurse why she should donate her own blood before surgery. How should the nurse respond?
- A. The blood bank is very short of blood.'
- B. Your own blood is the correct type for you.'
- C. It eliminates the chance of blood-borne diseases such as hepatitis and HIV.'
- D. Your own blood increases your energy level after surgery.'
Correct Answer: C
Rationale: Autologous blood donation eliminates transfusion-related infection risks, like hepatitis or HIV, ensuring safety during surgery.
The physician prescribes lithium carbonate (Lithobid) 300 mg PO QID for a 47-year-old woman. The nurse in the outpatient clinic teaches the client about the medication. The nurse should encourage the client to make sure her diet has adequate
- A. sodium.
- B. protein.
- C. potassium.
- D. iron.
Correct Answer: A
Rationale: alkali metal salt acts like sodium ions in body; excretion of lithium depends on normal sodium levels; sodium reduction causes marked lithium retention, leading to toxicity
An elderly client is oriented during the day but becomes disoriented during the evening.
Which of the following nursing actions is MOST appropriate?
- A. Place a clock where the client can see it.
- B. Restrain all four extremities.
- C. Keep a light on in the client's room.
- D. Place the side rails in an upright position.
Correct Answer: D
Rationale: Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) will provide visual cues, safety is more important (2) inappropriate (3) may be appropriate, but is not priority over answer choice #4 (4) correct-side rails should always be in an upright position for a disoriented client
A client with acute leukemia has developed oral ulcerations. The nurse can increase the client's comfort by suggesting that he:
- A. Avoid brushing his teeth until the ulcers heal.
- B. Rinse his mouth frequently with normal saline.
- C. Rinse his mouth frequently with hydrogen peroxide.
- D. Cleanse his teeth and mouth with lemon and glycerin swabs.
Correct Answer: B
Rationale: Normal saline rinses are gentle and help keep the mouth clean without irritating oral ulcerations.
The nurse is caring for a client with end stage renal disease. What action should the nurse take to assess for patency in a fistula used for hemodialysis?
- A. Observe for edema proximal to the site
- B. Irrigate with 5 ml of 0.9% Normal Saline
- C. Palpate for a thrill over the fistula
- D. Check color and warmth in the extremity
Correct Answer: C
Rationale: Palpate for a thrill over the fistula. A thrill indicates patency of the fistula.