Nokea
The patient has a calcium level of 12.1 mg/dL. Which nursing action should the nurse include on the care plan?
- A. Maintain the patient on bed rest.
- B. Auscultate lung sounds every 4 hours.
- C. Monitor for Trousseau's and Chvostek's signs.
- D. Encourage fluid intake up to 4000 mL every day.
Correct Answer: D
Rationale: The correct answer is D: Encourage fluid intake up to 4000 mL every day. High calcium levels can lead to dehydration, so encouraging fluid intake helps prevent this complication. Increased fluid intake also promotes calcium excretion through urine. Bed rest (A) is not directly related to managing high calcium levels. Auscultating lung sounds (B) every 4 hours is more relevant for respiratory issues. Monitoring for Trousseau's and Chvostek's signs (C) is associated with low calcium levels, not high levels.
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What instruction should a patient with a history of hypertension be provided when being discharged with a prescription for a thiazide diuretic?
- A. Avoid foods high in potassium.
- B. Take the medication at bedtime.
- C. Monitor weight daily.
- D. Limit fluid intake to 1 liter per day.
Correct Answer: C
Rationale: Rationale:
C is correct because thiazide diuretics can cause fluid retention, leading to weight gain, which may indicate worsening heart failure or hypertension. Daily weight monitoring helps detect fluid retention early, enabling timely intervention.
Summary:
A: Incorrect. Thiazide diuretics can cause potassium loss, so avoiding potassium-rich foods is not necessary.
B: Incorrect. Taking the medication in the morning is preferred to prevent nocturia and sleep disturbances.
D: Incorrect. Fluid intake should not be limited unless advised by a healthcare provider to prevent dehydration.
Which problem in a client requires the most immediate intervention by the nurse?
- A. Finger paresthesias related to carpal tunnel syndrome.
- B. Increasing sharp pain related to compartment syndrome.
- C. Increasing burning pain related to a Morton's neuroma.
- D. Increasing sharp pain related to plantar fasciitis.
Correct Answer: B
Rationale: The correct answer is B. Compartment syndrome is a medical emergency that can lead to tissue damage and loss of limb function. Immediate intervention is crucial to prevent further complications. Finger paresthesias related to carpal tunnel syndrome (A) are not life-threatening and can be managed conservatively. Morton's neuroma (C) and plantar fasciitis (D) are painful conditions, but they do not pose an immediate threat to the client's health or limb function.
When caring for a client with hepatic encephalopathy, why is a low-protein diet recommended by the nurse?
- A. Hyperglycemia
- B. Hypoglycemia
- C. Increased ammonia levels
- D. Electrolyte imbalance
Correct Answer: C
Rationale: The correct answer is C: Increased ammonia levels. In hepatic encephalopathy, the liver is unable to metabolize ammonia into urea, leading to increased ammonia levels in the blood. A low-protein diet helps reduce ammonia production in the gut, thereby decreasing ammonia levels in the blood and improving symptoms. Hyperglycemia (A) and hypoglycemia (B) are not directly related to the rationale for a low-protein diet in hepatic encephalopathy. Electrolyte imbalance (D) is not specifically addressed by a low-protein diet in this context.
A patient with coronary artery disease (CAD) is prescribed a statin medication. What should the nurse include in the patient education?
- A. Take the medication with food.
- B. Report any muscle pain or weakness.
- C. Increase intake of grapefruit juice.
- D. Avoid foods high in potassium.
Correct Answer: B
Rationale: Step 1: Statins can cause muscle pain or weakness as a side effect.
Step 2: Prompt reporting of muscle pain or weakness is crucial to address potential myopathy or rhabdomyolysis.
Step 3: Nurse should educate patient to report any muscle symptoms promptly for timely intervention and prevention of complications.
Summary: Option B is correct as it emphasizes the importance of monitoring and reporting potential side effects of statins. Options A, C, and D are incorrect as taking with food, increasing grapefruit juice intake, and avoiding potassium-rich foods are not relevant considerations for statin therapy.
Why is a low-protein diet recommended for a patient with renal failure?
- A. To prevent fluid overload
- B. To reduce nitrogenous waste
- C. To maintain electrolyte balance
- D. To prevent hyperglycemia
Correct Answer: B
Rationale: The correct answer is B: To reduce nitrogenous waste. In renal failure, the kidneys cannot effectively filter waste products like urea and creatinine, leading to their accumulation in the blood. A low-protein diet reduces the production of these nitrogenous wastes, lessening the burden on the kidneys.
A low-protein diet does not directly prevent fluid overload (A), maintain electrolyte balance (C), or prevent hyperglycemia (D) in renal failure. These functions are typically managed through other dietary modifications and treatments specific to each condition.