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The nurse is caring for a client with a history of cirrhosis who is receiving lactulose (Chronulac) 30 mL PO tid. Which of the following findings should the nurse report immediately?
- A. Ammonia level of 40 mcg/dL.
- B. Potassium 3.5 mEq/L.
- C. Diarrhea with 4 stools per day.
- D. Sodium 140 mEq/L.
Correct Answer: C
Rationale: Diarrhea with 4 stools per day suggests lactulose overdose, risking dehydration. Options A, B, and D are normal.
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A client has just been admitted with portal hypertension. Which nursing diagnosis would be a priority in planning care?
- A. Altered nutrition: less than body requirements
- B. Potential complication hemorrhage
- C. Ineffective individual coping
- D. Fluid volume excess
Correct Answer: B
Rationale: Potential complication hemorrhage. Esophageal varices are dilated and tortuous vessels of the esophagus that are at high risk for rupture if portal circulation pressures rise.
The physician diagnoses Graves' disease for a 28-year-old woman seen in the clinic. The nurse would expect the client to exhibit which of the following symptoms?
- A. Lethargy in the early morning.
- B. Sensitivity to cold.
- C. Weight loss of 10 lb in 3 weeks.
- D. Reduced deep tendon reflexes.
Correct Answer: C
Rationale: increased metabolic rate causes weight loss even with increased appetite
In order to be effective in administering cardiopulmonary resuscitation to a 5 year-old, the nurse must
- A. Assess the brachial pulses
- B. Breathe once every 5 compressions
- C. Use both hands to apply chest pressure
- D. Compress 80-90 times per minute
Correct Answer: B
Rationale: Breathe once every 5 compressions. For a 5 year-old, the nurse should give 1 breath for every 5 compressions.
The nurse is caring for a client who is receiving IV fluids at 150 mL/hour. Which of the following findings indicates fluid overload?
- A. Blood pressure of 120/80 mmHg.
- B. Heart rate of 80 bpm.
- C. Crackles in the lung bases.
- D. Urine output of 50 mL/hour.
Correct Answer: C
Rationale: Crackles in the lung bases suggest pulmonary edema from fluid overload. Options A, B, and D are normal findings.
The nurse is caring for a client who is postoperative day 1 after a pancreaticoduodenectomy (Whipple procedure). Which of the following findings should the nurse report immediately?
- A. Pain at the incision site.
- B. Temperature of 100.8°F (38.2°C).
- C. Nasogastric tube output of 200 mL.
- D. Urine output of 40 mL/hour.
Correct Answer: B
Rationale: A temperature of 100.8°F suggests infection, a serious post-Whipple complication. Options A, C, and D are normal.