Nokea
The nurse is caring for a client with a history of burns. Which of the following laboratory findings indicates a need for intervention?
- A. Serum potassium of 5.5 mEq/L.
- B. Serum sodium of 135 mEq/L.
- C. Hemoglobin of 12 g/dL.
- D. White blood cell count of 8,000/mm³.
Correct Answer: A
Rationale: Hyperkalemia (potassium 5.5 mEq/L) is a complication of burns due to tissue damage, requiring intervention.
You may also like to solve these questions
A client is admitted with acute glomerulonephritis. The nurse should monitor the client for which of the following?
- A. Hypertension.
- B. Hypokalemia.
- C. Polyuria.
- D. Hypoalbuminemia.
Correct Answer: A, D
Rationale: Acute glomerulonephritis can cause hypertension (due to fluid retention) and hypoalbuminemia (due to proteinuria).
A pregnant woman at 22 weeks' gestation is diagnosed with gonorrhea. The physician orders doxycycline (Vibramycin). The nurse should first:
- A. Inform the client about the effects of the drug.
- B. Make sure the record notes that the baby must receive eyedrops when born.
- C. Have the physician add a single dose of ceftriaxone (Rocephin).
- D. Discuss with the physician the need to change the order.
Correct Answer: D
Rationale: Doxycycline is contraindicated in pregnancy due to risks to the fetus. The nurse should discuss changing the order to a safer alternative, such as ceftriaxone, which is recommended for gonorrhea in pregnancy.
The nurse is teaching unlicensed assistive personnel about caring for a client who is withdrawing from alcohol and street drugs. Which of the following communication techniques when observed by the nurse indicate the UAP has understood the instructions? The UAP talks to the client using:
- A. Matter-of-fact manner and short sentences.
- B. Cheerful tone of voice, using humor when appropriate.
- C. Loud voice and giving general comments.
- D. Clear explanations in a quiet voice.
Correct Answer: A
Rationale: A matter-of-fact manner with short sentences is effective for clients withdrawing from substances, as it minimizes confusion and agitation.
A 12-year-old boy is admitted due to depression and post-trauma response. Child Protective Services reports that the boy's father is now in jail for molesting him from ages 6 to 9. Given the typical reactions of incest victims, the nurse should assess the child for which behavior? Select all that apply.
- A. Sexualized play.
- B. Aggression.
- C. Isolation at home.
- D. Running away.
- E. Truancy.
Correct Answer: A, B, C, D, E
Rationale: Incest victims may exhibit sexualized play, aggression, isolation, running away, and truancy as coping mechanisms or trauma responses.
A client has soft wrist restraints to prevent her from pulling out her nasogastric tube. Which of the following nursing interventions should be implemented while the restraints are on the client?
- A. Instruct the client not to move while the restraints are in place
- B. Remove the restraints every 4 hours to provide skin care
- C. Secure the restraints to side rails of the bed
- D. Check on the client every 30 minutes while the restraints are on
Correct Answer: D
Rationale: Checking the client every 30 minutes ensures safety, circulation, and skin integrity while restraints are in use. Restraints should be removed every 2 hours for care, not 4, and securing to side rails is unsafe.