Nokea
The nurse is reviewing prescriptions for assigned adult clients. The nurse should question the prescription for
- A. 0.45% sodium chloride for a client with syndrome of inappropriate antidiuretic hormone secretion who has a decreased sodium level
- B. 0.9% sodium chloride for a client with gastrointestinal bleeding who has a decreased hemoglobin level
- C. 1,000 mL bolus of 0.9% sodium chloride for a client with septic shock who has an increased WBC count
- D. lactated Ringer solution for a client with hypovolemic shock and a thermal burn who has an increased hematocrit level
Correct Answer: A
Rationale: 0.45% sodium chloride is hypotonic and can worsen hyponatremia in SIADH by further diluting serum sodium, requiring clarification for a hypertonic solution.
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The nurse is teaching an adult who has a broken ankle that has been casted how to climb stairs. The nurse knows that the client understands how to climb up stairs when she does which of the following?
- A. While bearing weight on the unaffected leg, the client moves the crutches up to the next step followed by the affected leg and then the unaffected leg.
- B. While bearing weight on the unaffected leg, the client moves affected leg to the next step followed by the unaffected leg and the crutches.
- C. While bearing weight on crutches, the client moves the affected leg to the next step followed by the unaffected leg and the crutches.
- D. While bearing weight on crutches, the client moves the unaffected leg to the next step followed by the affected leg and the crutches.
Correct Answer: D
Rationale: To climb stairs, weight is borne on crutches, moving the unaffected leg first, then the affected leg and crutches, ensuring stability and safety using the stronger leg.
The nurse is feeding a 3-month-old client with tetralogy of Fallot. During the feeding, the client becomes cyanotic and has difficulty breathing. Which action should the nurse take first?
- A. Administer oxygen via face mask to the client
- B. Administer subcutaneous morphine to the client
- C. Obtain the client's pulse oximetry reading
- D. Place the client in the knee-chest position
Correct Answer: D
Rationale: The knee-chest position increases systemic vascular resistance and reduces right-to-left shunting in tetralogy of Fallot, immediately improving oxygenation during a tet spell.
Following a typanoplasty, the nurse should maintain the client in which position?
- A. Semi-Fowler's with the operative ear facing down
- B. Low Trendelenburg with the head in neutral position
- C. Flat with the head turned to the side with the operative ear facing up
- D. Supine with a small neck roll to allow for drainage
Correct Answer: C
Rationale: After tympanoplasty, the client should be positioned flat with the head turned to the side and the operative ear facing up to promote healing and prevent pressure on the surgical site. Answer A is incorrect because the operative ear should face up, not down. Answer B is incorrect because low Trendelenburg is not indicated. Answer D is incorrect because a neck roll may not ensure proper positioning of the operative ear.
The nurse is suctioning the tracheostomy of an adult client. The recommended pressure setting is:
- A. 40-60 mm Hg
- B. 60-80 mm Hg
- C. 80-120 mm Hg
- D. 120-140 mm Hg
Correct Answer: C
Rationale: Suction pressure of 80-120 mm Hg is recommended for adult tracheostomy suctioning to effectively remove secretions without causing trauma.
An adult who has hepatitis A asks the nurse why her skin is yellow. The nurse should include which information when replying?
- A. The diseased liver is not able to convert bilirubin into bile, so bilirubin pigments stay in the bloodstream and cause the skin and sclera to turn yellow.
- B. The virus that causes hepatitis A leaves a yellow pigment in the bloodstream.
- C. The affected liver cells produce more bilirubin than usual, causing the skin to turn yellow.
- D. The body is trying to get rid of fecal waste products through the skin.
Correct Answer: A
Rationale: Hepatitis A impairs liver function, reducing bilirubin conjugation and excretion, leading to its accumulation in the blood, causing jaundice. The virus does not produce pigment, nor does the liver overproduce bilirubin or excrete waste through skin.