Nokea
Which electrolyte imbalance is a potential side effect of diuretics?
- A. Hyperkalemia
- B. Hypercalcemia
- C. Hypomagnesemia
- D. Hypokalemia
Correct Answer: D
Rationale: The correct answer is D, Hypokalemia. Diuretics commonly lead to hypokalemia, which is low potassium levels in the body. Hyperkalemia (choice A) is the opposite, indicating high potassium levels. Hypercalcemia (choice B) refers to elevated calcium levels, not typically associated with diuretics. Hypomagnesemia (choice C) is low magnesium levels and can also be a consequence of diuretic use, but potassium imbalance is more common.
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What intervention would be the most important for the nurse to implement for the client with a left nephrectomy?
- A. Assess the intravenous fluids for rate and volume
- B. Change the surgical dressing every day at the same time
- C. Monitor the client's medication levels daily
- D. Monitor the percentage of each meal eaten
Correct Answer: A
Rationale: The most important intervention for a client with a left nephrectomy is to assess the intravenous fluids for rate and volume. After nephrectomy, monitoring intravenous fluids is crucial to ensure proper hydration and kidney function. Changing the surgical dressing daily, monitoring medication levels, and tracking meal intake are also important aspects of care but not as critical as ensuring adequate intravenous fluid management post-surgery.
The nurse is caring for clients on a cardiac floor. Which client should the nurse assess first?
- A. The client with three (3) unifocal PVCs in a minute
- B. The client diagnosed with coronary artery disease who wants to ambulate
- C. The client diagnosed with mitral valve prolapse with an audible S3
- D. The client diagnosed with pericarditis who is in normal sinus rhythm
Correct Answer: C
Rationale: The correct answer is C because an audible S3 in a client with mitral valve prolapse could indicate heart failure, which requires immediate assessment. Choice A is less urgent as occasional unifocal PVCs are common. Choice B is important but can be addressed after the client with an audible S3. Choice D, a client with pericarditis in normal sinus rhythm, is stable compared to a client with potential heart failure symptoms.
What intervention would be most important for the nurse to implement for the client with a left nephrectomy?
- A. Assess the intravenous fluids for rate and volume
- B. Change the surgical dressing daily at the same time
- C. Monitor the client's medication levels daily
- D. Monitor the percentage of each meal eaten
Correct Answer: A
Rationale: The correct answer is A: Assess the intravenous fluids for rate and volume. After a nephrectomy, monitoring intravenous fluids is crucial to ensure proper hydration and kidney function. Choice B is incorrect because changing the surgical dressing daily is important but not the most critical intervention. Choice C is incorrect as monitoring medication levels daily may be necessary but is not the priority after a nephrectomy. Choice D is irrelevant to the immediate postoperative care needed after a nephrectomy.
The nurse is teaching the client diagnosed with colon cancer who is scheduled for a colostomy the next day. Which behavior indicates the best method of applying adult teaching principles?
- A. The nurse repeats the information as indicated by the client's questions
- B. The nurse teaches all the information needed by the client in one session
- C. The nurse uses a video to explain with medical terms to the client
- D. The nurse waits until the client asks questions about the surgery
Correct Answer: A
Rationale: Choice A is the best method of applying adult teaching principles because repeating information and addressing the client's questions as they arise is effective for reinforcing learning in adults. This approach allows for clarification of doubts and ensures that the client understands the information provided. Choice B is incorrect as teaching all the information in one session may overwhelm the client and hinder retention. Choice C is incorrect as using medical terms without ensuring the client's understanding may lead to confusion. Choice D is incorrect because waiting for the client to ask questions may result in missed opportunities to address important information proactively.
Which intervention should the nurse implement for the client who has an ileal conduit?
- A. Pouch the stoma with a one-inch margin around the stoma
- B. Refer the client to the United Ostomy Association for discharge teaching
- C. Report to the healthcare provider any decrease in urinary output
- D. Monitor the stoma for signs and symptoms of infection every shift
Correct Answer: C
Rationale: The correct intervention for a client with an ileal conduit is to report to the healthcare provider any decrease in urinary output. A decrease in urinary output can be indicative of a blockage or other complication, necessitating immediate attention. Choice A is incorrect because pouching the stoma with a margin around it is not directly related to managing complications. Choice B is incorrect as referring the client to an ostomy association may be beneficial for education but is not the immediate action needed for decreased urinary output. Choice D is incorrect because monitoring for infection, although important, is not the priority when dealing with a potential complication like decreased urinary output.