Nokea
A 30-year-old woman is admitted to the hospital with dry mucous membranes and decreased skin turgor. The woman's vital signs are BP 120/70, temperature 101°F (38.3°C), pulse 88, respirations 14. Laboratory Test s indicate the serum sodium is 150 mEq/L and the Hct is 48%.
The nurse would expect the physician to order which of the following IV fluids?
- A. D5 NS.
- B. 0.45% NaCl.
- C. 0.9% NaCl.
- D. Lactated Ringer's.
Correct Answer: B
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) hypertonic solutions contraindicated in dehydration (2) correct-hypotonic solution, shifts fluid into intracellular space to correct dehydration (3) isotonic solution, not best with dehydration (4) isotonic solution used to replace electrolytes
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The LPN/LVN is caring for an adult who has pneumonia. The nurse should instruct the nursing assistant to report which information immediately?
- A. Restlessness
- B. Pink-colored skin
- C. Nonproductive cough
- D. Dry mouth
Correct Answer: A
Rationale: Restlessness may indicate hypoxia in pneumonia, a critical symptom requiring immediate reporting to assess oxygenation status.
A college student comes to the college health services with complaints of a severe headache, nausea, and photophobia. The physician orders a complete blood count (CBC) and a lumbar puncture (LP). Which of the following lab results would the nurse expect if a diagnosis of bacterial meningitis were made?
- A. Cerebrospinal fluid (CSF) cloudy, Hgb 13 g/dL, Hct 38%, WBC 18,000/mm³.
- B. CSF with RBCs present, Hgb 10 g/dL, Hct 37%, WBC 8,000/mm³.
- C. CSF cloudy, Hgb 12 g/dL, Hct 37%, WBC 7,000/mm³.
- D. CSF clear, Hgb 15 g/dL, Hct 40%, WBC 11,000/mm³.
Correct Answer: A
Rationale: CSF normally clear, colorless; normal WBC 5,000-10,000 per cubic millimeter, normal Hgb (male 13.5-17.5 g/dL, female 12-16 g/dL), normal Hct (male 41-53%, female 36-46%)
The nurse is caring for a client who is receiving a continuous IV infusion of insulin for diabetic ketoacidosis. Which of the following laboratory results should the nurse report immediately?
- A. Blood glucose of 200 mg/dL.
- B. Potassium 3.0 mEq/L.
- C. pH of 7.30.
- D. Sodium 135 mEq/L.
Correct Answer: B
Rationale: Hypokalemia (3.0 mEq/L) risks arrhythmias during insulin therapy for DKA. Options A, C, and D are less urgent.
The nurse is assessing the mental status of a client admitted with possible organic brain disorder. Which of these questions will best assess the functioning of the client's recent memory?
- A. Name the year. What season is this?
- B. Subtract 7 from 100 and then subtract 7 from that. Now continue to subtract 7 from the new number.
- C. I am going to say the names of three things and I want you to repeat them after me: blue, ball, pen.
- D. What is this on my wrist? Then ask, What is the purpose of it?
Correct Answer: C
Rationale: I am going to say the names of three things and I want you to repeat them after me: blue, ball, pen. This tests immediate recall, a component of recent memory.
The nurse is administering a tuberculin skin test. How should the nurse insert the needle when administering the skin test?
- A. At a 10-degree angle
- B. At a 30-degree angle
- C. At a 60-degree angle
- D. At a 90-degree angle
Correct Answer: A
Rationale: A tuberculin skin test requires intradermal injection at a 10-degree angle to form a wheal under the skin. Other angles are used for subcutaneous or intramuscular injections.