Nokea
Laboratory reference ranges
Potassium3.5-5.0 mEq/L(3.5-5.0 mmol/L)
INRNormal: 0.8-1.1Therapeutic: 1.5-4.0
The nurse recognizes which of the following factors as possibly contributing to a sentinel event?
- A. Administered warfarin to a client with an INR of 6.0
- B. Administered flumazenil to a client who overdosed on lorazepam
- C. Initiated nitroprusside infusion in a client with blood pressure of 210/112 mm Hg
- D. Administered insulin/dextrose to a client with potassium level of 7.2 mEq/L (7.2 mmol/L)
Correct Answer: A
Rationale: Administering warfarin with an INR of 6.0 (therapeutic range 2.0-3.0) risks severe bleeding, a sentinel event. Flumazenil is appropriate for lorazepam overdose, nitroprusside for hypertensive crisis, and insulin/dextrose for hyperkalemia are correct interventions.
You may also like to solve these questions
A diabetic client asks the nurse why she should use a diaphragm as a method of contraception instead of birth control pills. The best explanation for the use of a diaphragm is:
- A. A diaphragm will best prevent pregnancy because oral contraceptives are rendered ineffective by increased glucose levels.
- B. A diaphragm is a noninvasive method of contraception that will not alter the blood glucose levels.
- C. A diaphragm will provide intrauterine contraception by preventing implantation of the embryo.
- D. A diaphragm is a noninvasive method of contraception that prevents the egg from being released from the ovary.
Correct Answer: B
Rationale: A diaphragm does not affect blood glucose, unlike oral contraceptives, which can alter glycemic control. Oral contraceptives are not ineffective due to glucose levels, diaphragms do not prevent implantation or ovulation, and they are not intrauterine.
The nurse is caring for a client who is very demanding. She frequently rings the bell and asks to have her pillow fluffed or the water glass filled. Which response by the nurse will likely be most effective?
- A. Answer the bell quickly each time she rings
- B. Say, 'I do not have time to be in your room constantly.'
- C. Say, 'Why are you so upset?'
- D. Say, 'You seem concerned about something.'
Correct Answer: D
Rationale: Acknowledging potential underlying concerns invites the client to express needs, reducing demands. Constant responses reinforce behavior, and dismissive or confrontational responses escalate tension.
The nurse in an outpatient clinic is caring for a client at 34 weeks gestation. The client is taking ferrous sulfate for anemia and reports constipation. Which of the following recommendations should the nurse reinforce for this client? Select all that apply.
- A. Decreased daily intake of dairy products
- B. Increased intake of fruits and vegetables
- C. Moderate-intensity exercise regularly
- D. One stimulant laxative daily for a week
- E. Two cups of hot coffee each morning
Correct Answer: B,C
Rationale: Fruits and vegetables provide fiber, and exercise promotes bowel motility, relieving constipation. Dairy may worsen constipation, stimulant laxatives are not first-line in pregnancy, and coffee is not a primary solution.
The nurse is assisting with the removal of a client’s chest tube. Which of the following actions should the nurse take? Select all that apply.
- A. Ensure the client is given an analgesic 30-60 minutes before tube removal
- B. Instruct the client to breathe in, hold it, and bear down while the tube is being removed
- C. Place the client in the Trendelenburg position
- D. Prepare a sterile airtight petroleum jelly gauze dressing
- E. Provide the health care provider with sterile suture removal equipment
Correct Answer: A,B,D,E
Rationale: Analgesics reduce pain, Valsalva maneuver (bear down) prevents air entry, petroleum gauze seals the site, and suture equipment is needed. Trendelenburg is not indicated for chest tube removal.
A laboring woman prefers to lie in the supine position during labor. The nurse teaches her that this is not a good position for which reason?
- A. It will cause more back pressure.
- B. Her baby will not come down well into the pelvis.
- C. Her blood pressure may drop and cause the baby's heart rate to drop.
- D. Contractions will be too close together, not giving her a rest.
Correct Answer: C
Rationale: Supine position can compress the vena cava, causing maternal hypotension and reduced fetal perfusion, leading to fetal heart rate drops.