Nokea
The nurse is caring for a client with a serum potassium level of 3.5 mEq/L. The client is placed on a cardiac monitor and receives 40 mEq potassium chloride in 1000 ml of 5% dextrose in water IV. Which of the following EKG patterns indicates to the nurse that the infusions should be discontinued?
- A. Narrowed QRS complex
- B. Shortened "PR"? interval
- C. Tall peaked "T"? waves
- D. Prominent "U"? waves
Correct Answer: C
Rationale: A tall peaked T wave is a characteristic EKG pattern associated with hyperkalemia. Hyperkalemia refers to high levels of potassium in the blood, which can lead to cardiac arrhythmias and other serious complications. Tall peaked T waves are a red flag for potential cardiac issues and can indicate the need to discontinue potassium infusions. The other choices, such as narrowed QRS complex, shortened "PR"? interval, and prominent "U"? waves, are not typically associated with hyperkalemia. Therefore, recognizing tall peaked T waves is crucial for the nurse to take prompt action in managing the client's condition.
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The client is seven (7) days post total hip replacement. Which statement by the client requires the nurse's immediate attention?
- A. I have bad muscle spasms in my lower leg of the affected extremity.
- B. I just can't 'catch my breath' over the past few minutes and I think I am in grave danger.
- C. I have to use the bedpan to pass my water at least every 1 to 2 hours.
- D. It seems that the pain medication is not working as well today.
Correct Answer: B
Rationale: While all statements by the client require attention, the most critical one that demands immediate action is option B. Clients who have undergone hip or knee surgery are at an increased risk of postoperative pulmonary embolism. Sudden dyspnea and tachycardia are hallmark signs of this condition. Without appropriate prophylaxis such as anticoagulant therapy, deep vein thrombosis (DVT) can develop within 7 to 14 days after surgery, potentially leading to pulmonary embolism. It is crucial for the nurse to recognize signs of DVT, which include pain, tenderness, skin discoloration, swelling, or tightness in the affected leg. Signs of pulmonary embolism include sudden onset dyspnea, tachycardia, confusion, and pleuritic chest pain. Option B indicates a potentially life-threatening situation that requires immediate intervention to prevent serious complications.
When administering a shot of Vitamin K to a 30-day-old infant, which of the following target areas is the most appropriate?
- A. Gluteus maximus
- B. Gluteus minimus
- C. Vastus lateralis
- D. Vastus medialis
Correct Answer: C
Rationale: When administering medications to infants, it is common to use the vastus lateralis muscle in the thigh for injections. The preferred site is the junction of the upper and middle thirds of the vastus lateralis muscle. This area provides a good muscle mass for the injection and minimizes the risk of hitting nerves or blood vessels. The gluteus maximus and gluteus minimus are not typically used for infant injections due to the risk of injury to the sciatic nerve. The vastus medialis is not as commonly used as the vastus lateralis for infant injections.
A child is admitted to the hospital with a diagnosis of Wilms tumor, stage II. Which of the following statements most accurately describes this stage?
- A. The tumor is less than 3 cm in size and requires no chemotherapy.
- B. The tumor did not extend beyond the kidney and was completely resected.
- C. The tumor extended beyond the kidney but was completely resected.
- D. The tumor has spread into the abdominal cavity and cannot be resected.
Correct Answer: C
Rationale: In Wilms tumor staging, stage II indicates that the tumor extends beyond the kidney but is completely resected. This means that the tumor has spread beyond the kidney but has been successfully removed. Choices A and B are incorrect because a tumor less than 3 cm in size and a tumor that did not extend beyond the kidney do not align with the characteristics of stage II Wilms tumor. Choice D is also incorrect as it describes a more advanced stage where the tumor has spread into the abdominal cavity and cannot be completely resected. Therefore, the correct answer is C, as it accurately reflects the characteristics of a stage II Wilms tumor.
The nurse is preparing to administer an enteral feeding to a client via a nasogastric feeding tube. The most important action of the nurse is:
- A. Verify correct placement of the tube
- B. Check that the feeding solution matches the dietary order
- C. Aspirate gastric contents to determine the amount of the last feeding remaining in the stomach
- D. Ensure that the feeding solution is at room temperature
Correct Answer: A
Rationale: The most crucial action for the nurse when preparing to administer enteral feeding via a nasogastric tube is to verify the correct placement of the tube. Proper placement of the tube is vital to prevent complications such as aspiration into the lungs. The definitive methods to confirm the position of the nasogastric tube include visualization through an x-ray or aspirating stomach contents and checking their pH (usually pH 1 to 5). Aspirated stomach content can also be tested for bilirubin to confirm placement in the stomach.
Choice B, checking that the feeding solution matches the dietary order, is important for ensuring the correct nutrition is provided but is not as critical as verifying tube placement to prevent potential harm.
Choice C, aspirating gastric contents to determine the amount of the last feeding remaining in the stomach, is a common nursing practice but is not the most crucial action when compared to ensuring correct tube placement.
Choice D, ensuring that the feeding solution is at room temperature, is relevant for patient comfort and preventing thermal injury but is not as essential as confirming correct tube placement to prevent serious complications.
A client is brought into the emergency room where the physician suspects that he has cardiac tamponade. Based on this diagnosis, the nurse would expect to see which of the following signs or symptoms in this client?
- A. Fever, fatigue, malaise
- B. Hypotension and distended neck veins
- C. Cough and hemoptysis
- D. Numbness and tingling in the extremities
Correct Answer: B
Rationale: Cardiac tamponade occurs when fluid or blood accumulates in the pericardium, preventing the heart from contracting properly. This leads to decreased cardiac output and is considered a medical emergency. Classic signs of cardiac tamponade include hypotension (low blood pressure) and distended neck veins due to the increased pressure around the heart. These signs result from the compromised ability of the heart to pump effectively. Choices A, C, and D are not typically associated with cardiac tamponade. Fever, fatigue, and malaise are non-specific symptoms that can be seen in various conditions. Cough and hemoptysis are more commonly associated with respiratory conditions, while numbness and tingling in the extremities are neurological symptoms not typically seen in cardiac tamponade.