Nokea
The nurse is caring for a client with an unstable spinal cord injury at the T7 level. Which intervention should take priority in planning care?
- A. Increase fluid intake to prevent dehydration
- B. Place client on a pressure reducing support surface
- C. Use skin care products designed for use with incontinence
- D. Increase caloric intake to aid healing
Correct Answer: B
Rationale: Place client on a pressure reducing support surface. This prevents skin breakdown due to immobility and reduced sensation.
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The nurse is caring for a client with a history of heart failure who is receiving lisinopril (Prinivil) 10 mg PO daily. Which of the following laboratory results would be of GREATest concern to the nurse?
- A. Potassium 5.5 mEq/L.
- B. Sodium 138 mEq/L.
- C. Creatinine 1.2 mg/dL.
- D. Calcium 9.0 mg/dL.
Correct Answer: A
Rationale: Hyperkalemia (potassium 5.5 mEq/L) is a serious complication of lisinopril, an ACE inhibitor, risking arrhythmias in heart failure. Options B, C, and D are normal: sodium 138 mEq/L, creatinine 1.2 mg/dL, and calcium 9.0 mg/dL do not indicate complications.
During administration of oral medications to an elderly, confused client, the client states, 'These pills look funny. They belong to the lady down the hall.' Which of the following is the BEST response by the nurse?
- A. Your physician has ordered new medications for you. They will help you get well.
- B. Remember yesterday when I brought your medications? They look the same.
- C. I'll explain why you are receiving these medications.
- D. I'll be back after I check your medications again.
Correct Answer: D
Rationale: Rechecking medications ensures safety, addressing the client’s concern about a possible error. Options A, B, and C risk administering incorrect drugs.
A client with bipolar disorder receives Eskalith (lithium carbonate) bid. Which observation is associated with lithium toxicity?
- A. Hyporeflexia
- B. Akathesia
- C. Ataxia
- D. Petechiae
Correct Answer: C
Rationale: Ataxia , or impaired coordination, is a sign of lithium toxicity. Hyporeflexia is not typical. Akathesia is restlessness, often linked to antipsychotics. Petechiae indicate bleeding issues, not lithium toxicity.
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.
The nurse is participating in a community health fair. As part of the assessments, the nurse should conduct a mental status examination when
- A. An individual displays restlessness
- B. There are obvious signs of depression
- C. Conducting any health assessment
- D. The resident reports memory lapses
Correct Answer: C
Rationale: Conducting any health assessment. A mental status examination is a critical part of baseline health assessments.