Nokea
The nurse is caring for a client with hyperemesis gravidarum. What is the most likely electrolyte imbalance?
- A. Hypocalcemia
- B. Hypomagnesemia
- C. Hyponatremia
- D. Hypokalemia
Correct Answer: D
Rationale: In hyperemesis gravidarum, where the client experiences severe nausea and vomiting, the most likely electrolyte imbalance is hypokalemia. Potassium is abundant in the stomach, and excessive vomiting leads to potassium loss. Hypocalcemia (Choice A) is not typically associated with hyperemesis gravidarum. Hypomagnesemia (Choice B) and Hyponatremia (Choice C) are less likely to occur compared to hypokalemia in this condition.
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While making rounds at 3 am, the nurse discovers a small fire in a client's room. What should the nurse do first?
- A. Remove the client from the room immediately.
- B. Leave the client's room to obtain a fire extinguisher.
- C. Instruct a nurse tech to pull the fire alarm.
- D. Evacuate all clients from the unit.
Correct Answer: A
Rationale: During a fire emergency, the priority is the safety of the individual in the room where the fire is located. Removing the client from the room immediately is the first step in the RACE acronym for fire safety: Rescue/Remove, Alarm, Contain, and Extinguish. This action ensures the client's safety before addressing the fire itself. Choice B is incorrect as leaving the client's room to obtain a fire extinguisher can delay the immediate removal of the client from the danger. Choice C is incorrect as pulling the fire alarm should be done after ensuring the client's safety. Choice D is incorrect as evacuating all clients from the unit should come after ensuring the safety of the individual in immediate danger.
The client with ulcerative colitis calls the clinic and reports increasing abdominal pain and increased frequency of loose stools. He asks to clarify what type of diet he is to follow. Which diet is best for clients with ulcerative colitis?
- A. High vitamin
- B. High calorie
- C. Low sugar
- D. Low fiber
Correct Answer: D
Rationale: The correct answer is 'Low fiber.' Clients with ulcerative colitis should follow a low-residue diet, which means consuming low fiber to reduce the frequency and volume of stools, helping to alleviate symptoms such as abdominal pain and diarrhea. High fiber diets can worsen the condition by stimulating bowel movements. Choice A, 'High vitamin,' is incorrect as the focus is on fiber content rather than vitamins. Choice B, 'High calorie,' is not specifically recommended for ulcerative colitis and may not address the symptoms effectively. Choice C, 'Low sugar,' does not directly address the dietary needs of clients with ulcerative colitis as the issue is more related to fiber intake than sugar consumption.
The schizophrenic client who is admitted to the hospital for possible bowel obstruction has an NG tube and complains of pain. What should the nurse do at this time?
- A. Decrease the stimuli and observe frequently
- B. Administer the PRN sedative
- C. Call the physician immediately
- D. Administer the PRN pain medication
Correct Answer: D
Rationale: In this scenario, the nurse should administer the PRN (as needed) pain medication to address the schizophrenic client's complaint of pain. It is essential to provide relief and comfort to the client experiencing pain. Option A, decreasing stimuli and observing frequently, may not address the underlying cause of pain and delay relief. Option B, administering a sedative, does not target the pain but may mask symptoms. Option C, calling the physician immediately, while important in some situations, is not the most immediate action needed to alleviate the client's pain. Therefore, the most appropriate action at this time is to administer the PRN pain medication to help alleviate the client's discomfort.
For which adverse effect of the block does the postpartum nurse monitor the woman after receiving a subarachnoid (spinal) block for a cesarean delivery?
- A. Headache
- B. Pruritus
- C. Vomiting
- D. Hypertension
Correct Answer: A
Rationale: The correct answer is 'Headache.' Postdural headache is a common adverse effect associated with a subarachnoid block due to cerebrospinal fluid leakage at the site of dural puncture. This headache worsens when the woman is upright and may improve when she lies flat. To manage this headache, bed rest and adequate hydration are recommended. Pruritus, vomiting, and hypertension are not typically associated with subarachnoid blocks. Pruritus, nausea, and vomiting are more commonly linked to the use of intrathecal opioids.
Which infection control measure is the priority for the nurse to implement in the care provided for a child admitted to the hospital with bacterial meningitis?
- A. Place the child in a private room
- B. Gowns and masks must be worn by all personnel in the child's room
- C. Visitors are restricted to parents only
- D. Hand washing is required by all personnel and visitors having contact with the child
Correct Answer: B
Rationale: The priority control measure for the nurse to implement in caring for a child with bacterial meningitis is ensuring that gowns and masks are worn by all personnel in the child's room. This measure is crucial as the child with bacterial meningitis is contagious for at least 24 hours after starting antibiotics, necessitating airborne precautions to prevent the spread of infection to healthcare workers and other patients. Placing the child in a private room (Choice A) is important but secondary to preventing infection transmission. Restricting visitors to parents only (Choice C) is also significant but not as critical as ensuring proper infection control measures. While hand washing (Choice D) is essential, the immediate need to prevent airborne transmission in the child's room takes precedence.