Nokea
The nurse is reviewing morning labs for a client. Which lab value requires immediate intervention by the nurse?
- A. calcium 9.8 mg/dL
- B. sodium 137 mEq/L
- C. chloride 104 mEq/L
- D. potassium 3.1 mEq/L
Correct Answer: D
Rationale: Potassium 3.1 mEq/L (D) indicates hypokalemia, requiring immediate intervention due to risk of arrhythmias. Calcium (A), sodium (B), and chloride (C) are within normal ranges.
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The nurse is performing hemodialysis on a client, with the understanding that air embolus is a complication of this treatment. Which assessment findings by the nurse indicate an air embolus?
- A. cold intolerance
- B. chest pain and anxiety
- C. decreased respirations
- D. hypertension and widening pulse pressure
Correct Answer: B
Rationale: Air embolus during hemodialysis causes chest pain and anxiety (B) due to air blocking pulmonary circulation. Cold intolerance (A), decreased respirations (C), and hypertension (D) are not typical signs.
The nurse is teaching a newly diagnosed client about Guillain-Barré syndrome (GBS). What information would the nurse provide in her teaching? Select all that apply.
- A. GBS affects females more often than males.
- B. The acute period lasts several days to 2 weeks.
- C. GBS tends to be self-limiting with temporary paralysis.
- D. Common symptoms include muscle weakness and paralysis.
- E. Infections such as Epstein-Barr virus have been associated with GBS.
Correct Answer: C,D,E
Rationale: GBS is self-limiting with temporary paralysis (C), causes muscle weakness/paralysis (D), and is linked to infections like Epstein-Barr (E). It affects males slightly more (A), and the acute phase lasts weeks to months (B).
A 47-year-old client presents to the emergency department with severe hypotension, muscle weakness, fatigue, and vomiting. Labs reveal a potassium level of 6.1 mEq/L and a sodium level of 128 mEq/L. Which of the following should the nurse anticipate for this client?
- A. administration of IV spironolactone
- B. boluses of Lactated Ringer's to increase blood pressure
- C. administration of IV saline, dextrose, or hydrocortisone
- D. boluses of 0.45% normal saline with 40 mEq/L of potassium
Correct Answer: C
Rationale: Symptoms and labs suggest Addisonian crisis (hypotension, hyperkalemia, hyponatremia). IV saline, dextrose, and hydrocortisone (C) stabilize the client. Spironolactone (A) worsens hyperkalemia, Lactated Ringer's (B) is less specific, and potassium (D) is contraindicated.
The nurse is providing teaching to a client newly diagnosed with type 2 diabetes. Which should the nurse include in her teaching?
- A. check the feet daily
- B. have eye examinations every 2 years
- C. use a heating pad to keep the feet warm
- D. take extra insulin before consuming sweets
Correct Answer: A
Rationale: Checking feet daily (A) prevents complications from neuropathy in type 2 diabetes. Eye exams are annual (B), heating pads (C) risk burns, and insulin (D) is not standard for type 2.
While in a restaurant the nurse notices a woman clutching her throat. The woman is unable to speak. The nurse asks the woman if she's choking, and she indicates yes. Which response by the nurse should be done first?
- A. establish an airway by tilting the chin back
- B. administer five quick chest compressions
- C. administer two rescue breaths
- D. perform the Heimlich maneuver
Correct Answer: D
Rationale: The Heimlich maneuver (D) is the first action for choking to dislodge the obstruction. Chin tilt (A) and breaths (C) are for unconscious patients, and chest compressions (B) are for cardiac arrest.