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What precaution should a nurse take to minimize the risk of death when using potassium chloride to flush a lock or central venous catheter?
- A. Use a dilute form of potassium chloride before flushing locks.
- B. Warm the potassium chloride before flushing locks.
- C. Document on the client’s chart.
- D. Ask the client to implement the instruction.
Correct Answer: A
Rationale: The correct answer is A because concentrated potassium chloride can cause cardiac arrest if injected rapidly.
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Tom arrives in the Emergency Room (ER) and is unable to move his legs as a result of an automobile accident that occurred 30 minutes ago. You respond by saying
- A. Swelling due to the initial trauma prevents you from moving your legs.
- B. There are good rehabilitation centers that will help restore sensation to your legs.
- C. Swelling due to the initial trauma may make the injury seem more severe than it actually is. A more accurate assessment will be made once the swelling goes down.
- D. You should have been wearing your seatbelt.
Correct Answer: C
Rationale: Initial swelling can mask the true extent of spinal injuries.
What considerations and interventions should be used when caring for a client with a hearing impairment?
- A. Use written communication
- B. Speak loudly and slowly
- C. Provide visual aids
- D. All of the above
Correct Answer: D
Rationale: Using multiple strategies ensures effective communication and accommodation for the client's needs.
6. What is the rationale behind many nurses advocating complementary and alternative therapies?
- A. They promote self-care and self-determination by patients.
- B. They are congruent with a view of humans as holistic beings.
- C. They are less expensive for patients than conventional therapies.
- D. They cause few adverse effects while achieving positive outcomes.
Correct Answer: B
Rationale: Many nurses advocate CAM because it aligns with a holistic view of health, considering physical, emotional, and spiritual aspects, as stated in option B.
A healthcare professional is assessing a client who has a fracture of the femur. Vital signs are obtained on admission and again in 2 hours. Which of the following changes in assessment should indicate to the healthcare professional that the client could be developing a serious complication?
- A. Increased respiratory rate from 18 to 44/min
- B. Increased oral temperature from 36.6° C (97.8° F) to 37° C (98.6° F)
- C. Increased blood pressure from 112/68 to 120/72 mm Hg
- D. Increased heart rate from 68 to 72/min
Correct Answer: A
Rationale: Step 1: Increased respiratory rate from 18 to 44/min indicates potential respiratory distress, a serious complication post-fracture.
Step 2: Rapid breathing can signify hypoxemia, pulmonary embolism, or infection, requiring immediate intervention.
Step 3: Increased oral temperature and blood pressure within normal range are not as critical as respiratory distress.
Step 4: A slight increase in heart rate is common after a fracture and not indicative of a serious complication.
Jane, an obese hypertensive homemaker, complains of continual hunger and lack of energy. What nursing measure would be most helpful?
- A. Giving her a list of low-calorie foods
- B. Discussing the importance of eating breakfast
- C. Recommending a strict vegetarian diet
- D. Suggesting vitamin supplements
Correct Answer: B
Rationale: Eating breakfast helps regulate metabolism and energy levels throughout the day, reducing hunger and fatigue.