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When reviewing a client's fluid and electrolyte status, what should the nurse report to the provider?
- A. Potassium 5.4
- B. Sodium 140
- C. Calcium 8.6
- D. Magnesium 2.0
Correct Answer: A
Rationale: The correct answer is A: 'Potassium 5.4'. A potassium level of 5.4 is elevated (normal range is typically 3.5-5.0 mEq/L) and may indicate hyperkalemia, which can have serious cardiac implications. Elevated potassium levels can lead to life-threatening arrhythmias, so immediate reporting and intervention are necessary. Choice B, 'Sodium 140', falls within the normal range (135-145 mEq/L) and does not require immediate reporting. Choice C, 'Calcium 8.6', falls within the normal range (8.5-10.5 mg/dL) and is not an immediate concern. Choice D, 'Magnesium 2.0', is within the normal range (1.5-2.5 mEq/L) and does not need urgent reporting. Therefore, the nurse should prioritize reporting the elevated potassium level as it poses the most immediate risk.
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A client has been admitted to the hospital with severe diarrhea. The nurse should monitor the client for which complication?
- A. Metabolic acidosis
- B. Metabolic alkalosis
- C. Hyperkalemia
- D. Hypercalcemia
Correct Answer: A
Rationale: Severe diarrhea can lead to metabolic acidosis due to the loss of bicarbonate. When there is excessive loss of bicarbonate through diarrhea, the pH of the blood decreases, leading to metabolic acidosis. Metabolic alkalosis (Choice B) is not typically associated with severe diarrhea as it involves elevated pH and bicarbonate levels. Hyperkalemia (Choice C) is less likely with severe diarrhea as potassium is often lost along with fluids. Hypercalcemia (Choice D) is not a common complication of severe diarrhea; instead, hypocalcemia may occur due to malabsorption of calcium.
A client with rheumatoid arthritis is prescribed prednisone. What information should the LPN/LVN include when teaching the client about this medication?
- A. Take the medication with food to minimize gastrointestinal side effects.
- B. Avoid exposure to sunlight while taking this medication.
- C. Do not discontinue the medication abruptly.
- D. Increase fluid intake while taking this medication.
Correct Answer: C
Rationale: The correct answer is C: 'Do not discontinue the medication abruptly.' It is crucial for clients prescribed prednisone to not stop the medication suddenly to prevent adrenal insufficiency, as this medication suppresses the body's natural production of cortisol. Choice A is incorrect because prednisone should be taken with food to minimize gastrointestinal side effects, not necessarily to prevent stomach upset. Choice B is incorrect as there is no specific need to avoid sunlight while taking prednisone. Choice D is not directly related to prednisone use; while adequate fluid intake is generally beneficial, it is not a specific instruction for prednisone administration.
A client reports increased pain following physical therapy. Which of the following questions should be asked to assess the quality of the pain?
- A. Is your pain sharp or dull?
- B. Is your pain constant or intermittent?
- C. On a scale from 1 to 10, how severe is your pain?
- D. Where exactly is your pain located?
Correct Answer: A
Rationale: Correct Answer: A. Asking whether the pain is sharp or dull helps in determining the quality of the pain. Sharp pain is often associated with acute conditions, while dull pain may indicate chronic issues. Choices B, C, and D focus on different aspects of pain assessment. Option B pertains to the pattern of pain, either constant or intermittent. Option C addresses the severity of pain on a numerical scale. Option D inquires about the location of pain. While all these questions are essential in pain assessment, when specifically evaluating the quality of pain, distinguishing between sharp and dull sensations is crucial.
A client who is lactating is being taught about taking medications by a nurse. Which of the following actions should the nurse recommend to minimize the entry of medication into breast milk?
- A. Drink 8 oz of water with each dose of medication.
- B. Use medications that have a short half-life.
- C. Take each dose right after breastfeeding.
- D. Pump breast milk and discard it prior to feeding the newborn.
Correct Answer: C
Rationale: Taking medications immediately after breastfeeding helps minimize the amount of medication that enters breast milk. By doing so, there is a longer interval between the medication intake and the next breastfeeding session, reducing the concentration of the medication in breast milk. Options A and B are incorrect as drinking water with medication or using medications with a short half-life do not directly minimize the entry of medication into breast milk. Option D is unnecessary and wasteful as pumping and discarding breast milk before feeding is not as effective as timing medication intake with breastfeeding to reduce medication transfer into breast milk.
A client who has recently started using a behind-the-ear hearing aid is being cared for by a nurse. Which of the following statements should the nurse identify as an indication that the client understands the use of assistive devices?
- A. "I will be sure to remove my hearing aid before taking a shower."
- B. "I will keep my hearing aid in at all times, even when sleeping."
- C. "I will clean my hearing aid with alcohol."
- D. "I will turn off my hearing aid when not in use."
Correct Answer: A
Rationale: The correct answer is A. It is crucial for the client to remove the hearing aid before showering to prevent damage from moisture. Choice B is incorrect as wearing the hearing aid all the time, including during sleep, is not recommended and can cause discomfort or harm. Choice C is incorrect as alcohol can damage hearing aids; they should be cleaned with a solution recommended by the manufacturer to prevent harm. Choice D is incorrect because hearing aids should not be turned off when not in use; instead, they should be stored properly following the manufacturer's instructions to maintain functionality and battery life.