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In a client with asthma who develops respiratory acidosis, what should the nurse expect the client's serum potassium level to be?
- A. normal
- B. elevated
- C. low
- D. unrelated to the pH
Correct Answer: B
Rationale: In respiratory acidosis, the serum potassium level is expected to be elevated. This occurs because potassium shifts from cells into the bloodstream as a compensatory mechanism to maintain acid-base balance. Choices A, C, and D are incorrect. A normal potassium level is not expected in respiratory acidosis. A low potassium level is more commonly associated with alkalosis, not acidosis. The potassium level is indeed related to pH changes in respiratory acidosis, leading to the expected elevation.
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A 64-year-old Alzheimer's patient has exhibited excessive cognitive decline resulting in harmful behaviors. The physician orders restraints to be placed on the patient. Which of the following is the appropriate procedure?
- A. Secure the restraints to the bed rails on all extremities.
- B. Notify the physician that restraints have been placed properly.
- C. Communicate with the patient and family the need for restraints.
- D. Position the head of the bed at a 45-degree angle.
Correct Answer: C
Rationale: In cases where restraints are considered necessary for a patient, it is crucial to communicate effectively with both the patient and their family about the reasons for this decision. This helps ensure that all parties involved understand the necessity of restraints and are informed about the potential risks and benefits. Option A, securing restraints to the bed rails on all extremities, is not appropriate as it does not involve proper communication or ethical considerations. Option B, notifying the physician that restraints have been placed properly, overlooks the importance of patient and family involvement in decision-making. Option D, positioning the head of the bed at a 45-degree angle, is unrelated to the use of restraints and does not address the situation at hand.
If your patient is acutely psychotic, which of the following independent nursing interventions would not be appropriate?
- A. Conveying calmness through one-on-one interaction
- B. Recognizing and managing your own feelings to prevent escalation of the patient's anxiety level
- C. Encouraging client participation in group therapy
- D. Listening and identifying causes of their behavior
Correct Answer: C
Rationale: When a patient is acutely psychotic, they may not be able to effectively participate in group therapy due to their altered mental state. Group settings can be overwhelming and may exacerbate the patient's symptoms. Choices A, B, and D are appropriate interventions. Choice A is correct as providing calmness through one-on-one interaction can be beneficial in establishing trust and reducing anxiety. Choice B is also important as recognizing and managing the nurse's feelings can prevent further escalation of the patient's symptoms. Choice D is relevant as listening and identifying causes of the patient's behavior can aid in understanding and providing appropriate care tailored to the patient's needs.
A healthcare professional is reviewing a patient's serum glucose levels. Which of the following scenarios would indicate abnormal serum glucose values for a 30-year-old male?
- A. 70 mg/dL
- B. 55 mg/dL
- C. 110 mg/dL
- D. 100 mg/dL
Correct Answer: B
Rationale: The correct answer is 55 mg/dL. The standard range for serum glucose levels is typically 60-115 mg/dL. A serum glucose level of 55 mg/dL falls below this range, indicating hypoglycemia. Options A, C, and D are within the standard range for serum glucose levels and would not be considered abnormal for a 30-year-old male.
When caring for a client with a possible diagnosis of placenta previa, which of the following admission procedures should the nurse omit?
- A. perineal shave
- B. enema
- C. urine specimen collection
- D. blood specimen collection
Correct Answer: B
Rationale: The correct answer is 'enema.' Administering an enema to a client with placenta previa can dislodge the placenta, leading to an increased risk of bleeding and complications. It is crucial to avoid any interventions that may disrupt the placenta's positioning. Collecting urine and blood specimens are necessary for diagnostic purposes and monitoring, while a perineal shave is a routine procedure that does not pose a risk to the client with placenta previa.
A 32-year-old male with a complaint of dizziness has an order for Morphine via IV. What should the nurse do first?
- A. Check the patient's chest x-ray results.
- B. Retake vitals including blood pressure.
- C. Perform a neurological screening on the patient.
- D. Request the physician on-call to assess the patient.
Correct Answer: B
Rationale: The correct first action for the nurse to take in this situation is to retake the patient's vitals, including blood pressure. Dizziness can be a sign of hypotension, which may be a contraindication for administering Morphine. Checking the chest x-ray results (Choice A) would not be the priority in this case as addressing the dizziness is more urgent. Performing a neurological screening (Choice C) may be important but not the first step when a patient presents with dizziness and an order for Morphine. Requesting the physician to assess the patient (Choice D) should come after the initial assessment and vitals retake.