Nokea
The nurse performs a physical assessment on a client and observes the client demonstrate palmar flexion while obtaining the blood pressure. The nurse should take which action?
- A. Obtain the blood pressure on the client's calf
- B. Request an order for a magnesium level
- C. Assess the client's orthostatic blood pressure
- D. Obtain capillary blood glucose (CBG)
Correct Answer: B
Rationale: Palmar flexion (Trousseau's sign) suggests hypocalcemia or hypomagnesemia, warranting a magnesium level check.
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A client with benign prostatic hyperplasia (BPH) is post-operative following transurethral resection of the prostate (TURP) and is now receiving continuous bladder irrigation. Upon assessment, the nurse notes that the output from the urinary catheter has stopped. Which nursing intervention is most appropriate?
- A. Reinsert a new catheter
- B. Increase the infusion rate of the irrigation
- C. Attempt to dislodge a clot
- D. Contact the health care provider (HCP)
Correct Answer: C
Rationale: Attempting to dislodge a clot is appropriate to restore flow, as catheter obstruction is common post-TURP.
The nurse is planning care for a client with a low serum albumin level. Which of the following interventions should the nurse include in the client's plan of care?
- A. Obtain a capillary blood glucose
- B. Implement seizure precautions
- C. Implement strict bed rest
- D. Collaborate with a registered dietician
Correct Answer: D
Rationale: Low albumin requires dietary intervention, best managed with a dietician.
The nurse cares for a client with a potassium of 5.7 mEq/L (mmol/L) [3.5-5 mEq/L, mmol/L]. The nurse understands that this potassium level may be caused by Select all that apply.
- A. Cushing's disease.
- B. nasogastric tube suctioning.
- C. salt substitutes.
- D. hyperinsulinism.
- E. adrenal insufficiency.
Correct Answer: C,E
Rationale: Salt substitutes (potassium-based) and adrenal insufficiency (reduced aldosterone) cause hyperkalemia.
When assessing for dehydration, the nurse should observe for which of the following?
- A. Headache and increased urinary output
- B. Weight gain and edema
- C. Hypertension and decreased urinary output
- D. Hypotension, headache, and dry mucous membranes
Correct Answer: D
Rationale: Dehydration causes hypotension, headache, and dry mucous membranes due to fluid loss.
The following scenario applies to the next 6 items.
The nurse in the emergency department (ED) is caring for a 57-year-old male client.
Item 1 of 6
History and Physical
A 57-year-old male client with stage three small cell lung cancer. The client had suddenly become disoriented and did not recognize his family members and relatives. He reports severe lower extremity weakness and has had three episodes of diarrhea in the past four hours. The client is undergoing 6 cycles of chemotherapy with cisplatin and etoposide. He is currently taking a 14-day course of 15 mg of prednisone. He is on his third day of steroid treatment. He has a medical history of dyslipidemia and advanced chronic obstructive pulmonary disease.
Nurses' Notes
0759: Client is completely disoriented and required maximum assistance to the stretcher because of unsteady gait. Lung sounds clear bilaterally. Alopecia noted. Skin is warm and dry and normal for ethnicity. Peripheral pulses 2+. No skin tenting. Hyperactive bowel sounds in all quadrants. 20-gauge peripheral vascular access device placed in the left antecubital space. T 97.8° F (36.6° C) P 88 RR 21 BP 123/68 Pulse oximetry reading 91% on room air.
Laboratory Results
• Hemoglobin 14 g/dL [14-18 g/dL (140–180 g/L)]
• Hematocrit 42% (0.42) [42-52% (0.42-0.52)]
• White Blood Cell 11,000 mm3 [5-10 mm3]
• Platelet Count 140,000 mm3 [150-400 mm3 (150–400 × 109/L)]
• Glucose 139 mg/dL (7.72 mmol/L) [70–110 mg/dL (4-6 mmol/L)]
• Sodium 116 mEq/L [136–145 mEq/L (mmol/L)]
• Potassium 3.3 mEq/L [3.5–5.0 mEq/L (mmol/L)]
• Creatinine 0.7 mg/dL (61.88 mmol/L) [0.6–1.2 mg/dL (53–106 mmol/L)]
• Blood Urea Nitrogen 8 mg/dL (2.86 mmol/L) [10–20 mg/dL (3.6–7.1 mmol/L)]
• Serum Osmolality 277 mOsm/kg [285-295 mOsm/kg (285–295 mmol/kg)]
Which of the following assessment findings require immediate follow-up? Select all that apply.
- A. mental status
- B. reports of diarrhea
- C. serum sodium
- D. serum potassium
- E. white blood cell count
- F. serum glucose
- G. alopecia
Correct Answer: A,C,D,F
Rationale: Mental status changes, severe hyponatremia (116 mEq/L), hypokalemia (3.3 mEq/L), and elevated glucose (139 mg/dL) require immediate attention due to potential neurological and cardiac risks.