Nokea
The nurse is caring for a client with hypernatremia. Which prescribed intravenous fluid (IVF) would be appropriate?
- A. Dextrose 5% in water (D5W)
- B. 3% saline
- C. Lactated Ringer's 5% Dextrose in Water (D5LR)
- D. 0.9% saline
Correct Answer: A
Rationale: D5W is hypotonic and helps correct hypernatremia by diluting serum sodium levels.
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The nurse is planning care for a client with bipolar I disorder who is experiencing a manic episode. Which of the following interventions should the nurse include in the plan of care?
- A. Attend group therapy while hospitalized
- B. Confront aggressive behavior
- C. Provide structured solitary activities
- D. Provide small, frequent low-calorie foods
Correct Answer: C
Rationale: Structured solitary activities help reduce stimulation and manage manic behavior safely.
The nurse in the emergency department (ED) is caring for a 10-year-old client.
Item 5 of 5
Nurses' Notes
1322: 10-year-old client and his parents report an 8-day history of a brownish-raised lesion over the back of his left leg. The parents report that the size of the rash has increased. The parents report returning from a one-week camping trip three weeks ago. The parents deny efficacy with over-the-counter antihistamine creams. The client's parents deny that the child has had a fever but has felt 'warm' occasionally and endorsed an intermittent headache. They report an area of firmness in the child's groin. On assessment, there was an erythematous, raised, nonpainful, oval patch on the back of his left leg. This was an enlargement of an inguinal lymph node. The child is alert and fully oriented and denies any pain. Peripheral pulses palpable 2+. No cyanosis or edema in the extremities. Lung sounds clear bilaterally. The parents report that the child did not receive the seasonal influenza vaccine. He currently takes a multivitamin for iron deficiency anemia and was hospitalized one year ago for an appendectomy. The parents state that the child’s sibling had influenza one month ago. Vital signs: T 98.8°F (37.1°C); HR 78 beats/min; RR 16 breaths/min; BP 110/76 mm Hg. SpO2 97% on room air.
Progress Notes
1401: The client was evaluated. The rash is localized, raised, and appears like a bullseye. The client has inguinal lymphadenopathy. The client's recent camping trip supports the probability of a vector-borne illness—specifically, Lyme disease.
Orders
• laboratory tests: IgM and IgG antibodies
• doxycycline 100 mg capsule p.o. twice daily for fourteen days
• discharge client home
• follow-up with a primary care physician in two weeks
The nurse reviews and executes the physician's orders. Which of the following actions should the nurse take when performing venipuncture on a 10-year-old client?
- A. Identify the child by only checking their identification armband.
- B. Apply a cold compress to the area to promote vasodilation.
- C. Demonstrate the procedure using a stuffed animal.
- D. Allow the child to decide which arm they would like for the venipuncture.
- E. Ask the child if they want to help set up some equipment.
- F. Offer the child a sedative to help them relax before the procedure.
Correct Answer: C, D, E
Rationale: Demonstrating on a stuffed animal, allowing arm choice, and involving the child in setup reduce anxiety and promote cooperation. Cold compresses constrict vessels, and sedatives are not routinely offered.
The nurse is demonstrating the appropriate use of a car seat to a client. The nurse is demonstrating which level of prevention?
- A. Primary
- B. Secondary
- C. Tertiary
- D. Quaternary
Correct Answer: A
Rationale: Car seat education prevents injury, a primary prevention strategy.
The nurse is caring for a client seven hours postoperative following a subtotal thyroidectomy. The client reports peripheral numbness and tingling, muscle twitching, and spasms. The nurse anticipates a prescription for
- A. levothyroxine
- B. hydrocortisone
- C. thiamine
- D. calcium gluconate
Correct Answer: D
Rationale: These symptoms suggest hypocalcemia, a common complication post-thyroidectomy due to parathyroid gland disruption. Calcium gluconate is the appropriate treatment.
When assessing a postpartum client, a nurse notes that the client has soaked three perineal pads in the three hours since delivery. The nurse also notes a soft fundus. The initial action for the nurse would be which of the following?
- A. Insert vaginal packing
- B. Massage the client's fundus
- C. Apply an ice pack over the client's perineal area
- D. Administer packed red blood cells
Correct Answer: B
Rationale: A soft fundus and heavy bleeding suggest uterine atony, a common cause of postpartum hemorrhage. Fundal massage is the initial action to stimulate uterine contraction.