Nokea
The nurse is caring for a client with a history of chronic kidney disease. Which dietary restriction is most important?
- A. Low potassium
- B. Low calcium
- C. Low magnesium
- D. Low iron
Correct Answer: A
Rationale: Chronic kidney disease impairs potassium excretion, risking hyperkalemia, which can cause arrhythmias. Low potassium diets are critical. Calcium, magnesium, and iron are less commonly restricted.
You may also like to solve these questions
On assessment, the nurse learns that a chronic paranoid schizophrenic has been taking 'the blue pill' (haloperidol) in the morning and evening, and 'the white pill' (benztropine) right before bedtime. The nurse might suggest to the client that she try:
- A. Doubling the daily dose of benztropine
- B. Decreasing the haloperidol dosage for a few days
- C. Taking the benztropine in the morning
- D. Taking her medication with food or milk
Correct Answer: C
Rationale: Suggesting that a client increase a medication dosage is an inappropriate (and illegal) nursing action. This action requires a physician's order. To suggest that a client decrease a medication dosage is an inappropriate (and illegal) nursing action. This action requires a physician's order. This response is an appropriate independent nursing action. Because motor restlessness can also be a side effect of cogentin, the nurse may suggest that the client try taking the drug early in the day rather than at bedtime. Certain medications can cause gastric irritation and may be taken with food or milk to prevent this side effect.
The client is admitted with a possible myocardial infarction. The nurse would anticipate an order from the physician for which laboratory test?
- A. Creatine kinase
- B. Ammonia
- C. Myoglobin
- D. Troponin T
- E. Gamma-glutamyl transferase
- F. Bilirubin
Correct Answer: A, C, D
Rationale: Creatine kinase (A), myoglobin (C), and troponin T (D) are cardiac biomarkers elevated in myocardial infarction. Ammonia (B), gamma-glutamyl transferase (E), and bilirubin (F) are unrelated to acute cardiac events.
A client on the psychiatric unit is threatening other clients and staff,and interventions to distract him have not been successful. What action should the nurse take?
- A. Call security for assistance and administer PRN medication to calm the client
- B. Tell the client to calm down and ask him again if he would like to play cards
- C. Tell the client that if he continues this behavior he will lose recreational privileges
- D. Ignore the client since it is unlikely he will actually harm anyone
Correct Answer: A
Rationale: Threatening behavior that persists despite de-escalation attempts requires immediate intervention. Calling security ensures safety and PRN medication may help calm the client. The other options are unsafe or ineffective in managing acute agitation.
A client with a stroke and malnutrition has been placed on Total Parenteral Nutrition (TPN). The nurse notes air entering the client via the central line. Which initial action is most appropriate?
- A. Notify the physician.
- B. Elevate the head of the bed.
- C. Place the client in the left lateral decubitus position.
- D. Stop the TPN and hang D5 1/2 NS.
Correct Answer: C
Rationale: Air embolism is suspected. Placing the client in the left lateral decubitus position traps air in the right atrium, preventing pulmonary embolism. Notifying the physician (A), elevating the bed (B), or changing fluids (D) is secondary.
A 9-month-old infant visits her pediatrician for a routine visit. A developmental assessment was initiated by the nurse. Which skill would cause the nurse to be concerned about the infant's developmental progression?
- A. She sits briefly alone with assistance.
- B. She creeps and crawls.
- C. She pulls herself to her feet with help.
- D. She stands while holding onto furniture.
Correct Answer: A
Rationale: The 9-month-old infant can sit alone for long periods. Sitting briefly alone with assistance at this age suggests a developmental delay, warranting further evaluation.