Nokea
The physician has ordered a paracentesis for a client with severe abdominal ascites. Before the procedure, the nurse should:
- A. Provide the client with a urinal
- B. Prep the area by shaving the abdomen
- C. Encourage the client to drink extra fluids
- D. Request an ultrasound of the abdomen
Correct Answer: A
Rationale: Providing a urinal allows the client to empty their bladder, reducing the risk of bladder puncture during paracentesis.
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The physician has ordered intravenous fluid with potassium for a client admitted with gastroenteritis and dehydration. Before adding potassium to the intravenous fluid, the nurse should:
- A. Assess the urinary output
- B. Obtain arterial blood gases
- C. Perform a dextrostick
- D. Obtain a stool culture
Correct Answer: A
Rationale: Adequate urinary output (at least 30 mL/hr) must be confirmed before adding potassium to IV fluids to prevent hyperkalemia.
The nurse is monitoring the progress of a client in labor. Which finding should be reported to the physician immediately?
- A. The presence of scant bloody discharge
- B. Frequent urination
- C. The presence of green-tinged amniotic fluid
- D. Moderate uterine contractions
Correct Answer: C
Rationale: Green-tinged amniotic fluid indicates meconium, a sign of fetal distress requiring immediate reporting.
A client with AIDS has a viral load of 200 copies per ml. The nurse should interpret this finding as:
- A. The client is at risk for opportunistic diseases.
- B. The client is no longer communicable.
- C. The client's viral load is extremely low so he is relatively free of circulating virus.
- D. The client's T-cell count is extremely low.
Correct Answer: C
Rationale: A viral load of 200 copies/ml is low, indicating effective treatment and minimal circulating virus.
The nurse is caring for an elderly client who presents to the ED with poor appetite, confusion, and weakness. Lab work is ordered for the client. The nurse should immediately notify the health care provider for which lab result?
- A. chloride 99 mEq/L
- B. calcium 9.4 mg/dL
- C. sodium 118 mEq/L
- D. potassium 4.2 mEq/L
Correct Answer: C
Rationale: Severe hyponatremia (sodium 118 mEq/L) can cause confusion and weakness and requires immediate provider notification. Other values are within normal ranges.
The nurse is caring for a client with a long history of taking magnesium hydroxide for managing symptoms of peptic ulcer disease. Which finding in the client's medical history would be of concern to the nurse?
- A. asthma
- B. arthritis
- C. heart failure
- D. enlarged prostate
Correct Answer: C
Rationale: Magnesium hydroxide can cause fluid retention, worsening heart failure. Other conditions are not directly affected.