Nokea
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 would be of GREATest concern to the nurse?
- A. Ammonia level of 40 mcg/dL.
- B. Potassium of 3.5 mEq/L.
- C. Diarrhea with 4 stools per day.
- D. Sodium of 140 mEq/L.
Correct Answer: C
Rationale: Diarrhea with 4 stools per day suggests lactulose overdose, risking dehydration and electrolyte imbalance in cirrhosis. Options A, B, and D are normal or expected: ammonia 40 mcg/dL is controlled, potassium 3.5 mEq/L is normal, and sodium 140 mEq/L is normal.
You may also like to solve these questions
The nurse is caring for a client in a manic phase of bipolar affective disorder. It is MOST important for the nurse to offer which of the following meals?
- A. Tuna salad sandwich and orange slices.
- B. Bologna sandwich and french fries.
- C. Milkshake and banana.
- D. Fried chicken and tossed salad.
Correct Answer: A
Rationale: Manic clients need portable, nutritious finger foods due to high energy and distractibility. Tuna salad sandwich and orange slices provide balanced nutrition. Options B, C, and D are less suitable: bologna is processed, milkshakes lack variety, and fried chicken is messy.
The nurse is caring for a client who is postoperative day 1 after a cesarean section. Which of the following findings would be of GREATest concern to the nurse?
- A. Temperature of 100.8°F (38.2°C).
- B. Pain at the incision site.
- C. Lochia rubra with small clots.
- D. Urine output of 50 mL/hour.
Correct Answer: A
Rationale: A temperature of 100.8°F suggests infection, such as endometritis, a serious complication post-cesarean section requiring immediate evaluation. Options B, C, and D are expected: incision pain, lochia rubra, and urine output 50 mL/hour are normal on day 1.
The nurse is caring for a client with a history of meningitis.
- A. Which precaution is most appropriate for a client with bacterial meningitis?
- B. Standard precautions.
- C. Droplet precautions.
- D. Contact precautions.
- E. Airborne precautions.
Correct Answer: B
Rationale: Droplet precautions are required for bacterial meningitis (e.g., Neisseria meningitidis) to prevent transmission via respiratory secretions. Standard precautions are insufficient, and contact or airborne precautions are incorrect.
The nurse is caring for a client with heart failure.
- A. Which symptom indicates worsening heart failure in a client?
- B. Weight gain of 2 pounds in 24 hours.
- C. Decreased blood pressure.
- D. Clear lung sounds bilaterally.
- E. Improved exercise tolerance.
Correct Answer: A
Rationale: A weight gain of 2 pounds in 24 hours indicates fluid retention, a sign of worsening heart failure. Decreased blood pressure may occur but is less specific, clear lung sounds suggest stability, and improved exercise tolerance indicates improvement.
A client has been taking furosemide (Lasix) for the past week. The nurse recognizes which finding may indicate the client is experiencing a negative side effect from the medication?
- A. Weight gain of 5 pounds
- B. Edema of the ankles
- C. Gastric irritability
- D. Decreased appetite
Correct Answer: D
Rationale: Decreased appetite. Lasix causes a loss of potassium if a supplement is not taken. Signs and symptoms of hypokalemia include anorexia, fatigue, nausea, decreased GI motility, muscle weakness, and dysrhythmias.