Nokea
The nurse is obtaining a history on an 80-year-old client. Which statement made by the client might indicate a potential for fluid and electrolyte imbalance?
- A. My skin is always so dry.
- B. I often use laxatives.
- C. I have always liked to drink a lot of ice tea.
- D. I sometimes have a problem with dribbling urine.
Correct Answer: B
Rationale: Frequent laxative use can lead to dehydration and electrolyte imbalances due to excessive fluid and electrolyte loss through diarrhea.
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Which of the following observations best indicates to the nurse that a paraplegic client can adequately carry out activities of daily living at home after discharge?
- A. The client can shave himself and brush his teeth.
- B. The client can transfer himself into and out of his wheelchair.
- C. The client can maneuver his wheelchair without difficulty.
- D. The client can prepare his own well-balanced meals.
Correct Answer: B
Rationale: essential if client is to perform ADLs
The doctor has ordered 80 mg of furosemide (Lasix) two times per day. The nurse notes the patient's potassium level to be 2.5 meq/L. The nurse should:
- A. Administer the Lasix as ordered
- B. Administer half the dose
- C. Offer the patient a potassium-rich food
- D. Withhold the drug and call the doctor
Correct Answer: D
Rationale: A potassium level of 2.5 mEq/L is dangerously low; withholding Lasix and notifying the doctor prevents further potassium loss.
A child is admitted to the emergency room following ingestion of a bottle of Children's Tylenol. The nurse is aware that Tylenol poisoning is treated with:
- A. Acetylcysteine
- B. Deferoximine
- C. Edetate calcium disodium
- D. Activated charcoal
Correct Answer: A
Rationale: Acetylcysteine is the antidote for acetaminophen (Tylenol) overdose, protecting the liver from toxicity.
The nurse is assisting a client to adjust crutches to the proper measurement. With the client in standing position, where should the tips of the crutches be placed?
- A. 2 to 3 inches directly to the side of the client's legs
- B. 4 to 6 inches to the side of the client's legs and 4 to 6 inches in front of feet
- C. 2 to 3 inches to the side of the client's legs and 4 to 6 inches in front of feet
- D. 4 to 6 inches directly to the side of the client's legs
Correct Answer: B
Rationale: Crutch tips should be 4-6 inches to the side and 4-6 inches in front of the feet (B) for stability and balance.
The nurse is caring for a client admitted to labor and delivery. The nurse is aware that the infant is in distress if she notes:
- A. Contractions every three minutes
- B. Absent variability
- C. Fetal heart tone accelerations with movement
- D. Fetal heart tone 120-130 bpm
Correct Answer: B
Rationale: Absent variability on the fetal monitor indicates fetal distress, suggesting compromised oxygenation.