Nokea
What is the most important nursing action when administering IV potassium?
- A. Monitor for decreased urine output
- B. Administer via IV push
- C. Administer slowly and dilute in IV fluids
- D. Ensure the client drinks 500 mL of water before administration
Correct Answer: C
Rationale: The most important nursing action when administering IV potassium is to administer it slowly and dilute it in IV fluids. This approach helps prevent irritation and hyperkalemia. Monitoring for decreased urine output (Choice A) is important but not as critical as ensuring the safe administration of IV potassium. Administering potassium via IV push (Choice B) is unsafe and can lead to adverse effects. Ensuring the client drinks water before administration (Choice D) is not directly related to the safe administration of IV potassium.
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A nurse in a long-term care facility is reviewing information about health care-associated infections with a newly licensed nurse. Which of the following information should the nurse include?
- A. Frequent hand washing prevents infection
- B. Prolonged use of corticosteroids increases infection risk
- C. Limit patient interaction to reduce infection spread
- D. Restrict client movement to prevent contamination
Correct Answer: B
Rationale: The correct answer is B because prolonged use of corticosteroids is a known risk factor for infections. Choice A is incorrect because frequent hand washing actually helps prevent infections. Choice C is incorrect as patient interaction is essential in healthcare but should be done following proper infection control measures. Choice D is also incorrect as restricting client movement is not a standard practice to prevent contamination.
A nurse is caring for a client who has coronary artery disease (CAD) and is receiving aspirin therapy. Which of the following findings should the nurse report to the provider?
- A. History of gastrointestinal bleeding
- B. Prothrombin time of 12 seconds
- C. Platelet count of 180,000/mm³
- D. Creatinine level of 1.0 mg/dL
Correct Answer: A
Rationale: The correct answer is A: History of gastrointestinal bleeding. Aspirin therapy is contraindicated in clients with a history of gastrointestinal bleeding because aspirin can further increase the risk of bleeding. Option B, prothrombin time of 12 seconds, is within the normal range and does not indicate a concern related to aspirin therapy. Option C, platelet count of 180,000/mm³, is also within the normal range and does not suggest a need for reporting to the provider in the context of aspirin therapy. Option D, creatinine level of 1.0 mg/dL, is within the normal range and is not directly related to aspirin therapy in this scenario.
How should a healthcare professional assess a patient with potential pneumonia?
- A. Assess lung sounds and monitor oxygen saturation
- B. Monitor for fever and sputum production
- C. Auscultate heart sounds and check for cyanosis
- D. Monitor for chest pain and administer oxygen
Correct Answer: A
Rationale: Correctly assessing a patient with potential pneumonia involves listening to lung sounds and monitoring oxygen saturation. Lung sounds can reveal abnormal breath sounds associated with pneumonia, such as crackles or diminished breath sounds. Oxygen saturation monitoring helps in detecting respiratory distress, a common complication of pneumonia. Monitoring for fever and sputum production (Choice B) is important but not as specific as assessing lung sounds and oxygen saturation. Auscultating heart sounds and checking for cyanosis (Choice C) are not primary assessments for pneumonia. Monitoring for chest pain and administering oxygen (Choice D) are relevant interventions but do not address the initial assessment of pneumonia.
Which of the following interventions should the nurse prioritize for a client with dementia who is at risk of falls?
- A. Use restraints to prevent the client from leaving the bed
- B. Use a bed exit alarm system to notify staff when the client attempts to leave the bed
- C. Encourage frequent ambulation with assistance
- D. Raise all four side rails to prevent falls
Correct Answer: B
Rationale: The correct answer is B. Using a bed exit alarm system is a non-restrictive intervention that alerts staff when the client tries to leave the bed, promoting safety and preventing falls. Choice A is incorrect because using restraints can have adverse effects and should be avoided whenever possible. Choice C is not the priority for a client at risk of falls due to dementia as it may increase the risk of falls without proper supervision. Choice D is also not recommended as raising all four side rails can lead to restraint and should be used cautiously, if at all. Therefore, the best option is to use a bed exit alarm system to ensure the client's safety while allowing some freedom of movement.
What are the early signs of hypoglycemia in a diabetic patient?
- A. Sweating and trembling
- B. Confusion and irritability
- C. Dizziness and increased heart rate
- D. Nausea and vomiting
Correct Answer: A
Rationale: The correct answer is A: 'Sweating and trembling.' These are classic early signs of hypoglycemia in a diabetic patient. Sweating occurs due to the activation of the sympathetic nervous system in response to low blood sugar levels, while trembling is a result of the body's attempt to increase muscle activity to raise blood sugar levels. Confusion and irritability (Choice B) are more advanced signs of hypoglycemia that occur if the condition is not treated promptly. Dizziness and increased heart rate (Choice C) can also occur but are not as specific and early as sweating and trembling. Nausea and vomiting (Choice D) are more commonly associated with other conditions or severe hypoglycemia, rather than being early signs.