Nokea
Which electrolyte imbalance is most concerning for a patient on loop diuretics?
- A. Hypokalemia
- B. Hyponatremia
- C. Hyperkalemia
- D. Hypercalcemia
Correct Answer: A
Rationale: The correct answer is hypokalemia. Loop diuretics can cause potassium depletion leading to hypokalemia, which is particularly concerning as it can result in cardiac arrhythmias. Hyponatremia (choice B) is not typically associated with loop diuretics. Hyperkalemia (choice C) is less common in patients on loop diuretics. Hypercalcemia (choice D) is not a typical electrolyte imbalance associated with loop diuretics.
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What is the best position for a patient experiencing shortness of breath?
- A. Supine position
- B. Semi-Fowler's position
- C. Trendelenburg position
- D. Prone position
Correct Answer: B
Rationale: The best position for a patient experiencing shortness of breath is the Semi-Fowler's position. This position promotes lung expansion and improves oxygenation by allowing the chest to expand more fully. The Supine position (lying flat on the back) may worsen breathing difficulties by reducing lung capacity. The Trendelenburg position (feet elevated higher than the head) is not recommended for patients with shortness of breath as it can increase pressure on the diaphragm and compromise breathing. The Prone position (lying face down) is also not suitable for patients experiencing shortness of breath as it may further restrict breathing.
What is the most appropriate action when a patient is experiencing confusion after surgery?
- A. Administer oxygen
- B. Reposition the patient
- C. Administer IV fluids
- D. Perform a neurological exam
Correct Answer: A
Rationale: Administering oxygen is the most appropriate action when a patient is experiencing confusion after surgery because it helps alleviate hypoxia, which may be causing the patient's confusion. Repositioning the patient would not directly address the potential hypoxia issue. Administering IV fluids may be necessary for hydration or other reasons but is not the initial priority in addressing confusion post-surgery. Performing a neurological exam may be important later on to assess the patient's neurological status but should not be the first action taken when confusion is present.
A nurse is planning care for a client who has a new prescription for warfarin. Which of the following laboratory values should the nurse monitor to determine the effectiveness of the therapy?
- A. Serum calcium level
- B. Platelet count
- C. INR
- D. WBC count
Correct Answer: C
Rationale: Corrected Rationale: The nurse should monitor the client's INR to determine the effectiveness of warfarin therapy. INR monitoring is crucial as it reflects the blood's ability to clot properly. Warfarin is commonly used as an anticoagulant, and maintaining the INR within the therapeutic range ensures that the client is protected from both clotting and bleeding events. Monitoring serum calcium levels, platelet count, or WBC count is not directly related to assessing the effectiveness of warfarin therapy.
A nurse is assessing a client who is receiving morphine via a patient-controlled analgesia (PCA) pump. Which of the following findings should the nurse report to the provider?
- A. Respiratory rate of 20/min
- B. Oxygen saturation of 93%
- C. Pain level of 2 on a scale of 0 to 10
- D. Blood pressure of 110/70 mm Hg
Correct Answer: D
Rationale: The correct answer is D because a blood pressure drop or other signs of morphine overdose should be reported, especially when using a PCA pump. Choices A, B, and C are within normal limits and do not indicate an immediate concern related to morphine administration.
What is the most important assessment for a patient with suspected pneumonia?
- A. Monitor lung sounds
- B. Check oxygen saturation
- C. Assess for cough
- D. Assess for fever
Correct Answer: A
Rationale: The most important assessment for a patient with suspected pneumonia is to monitor lung sounds. Lung sounds provide crucial information about the severity of pneumonia, such as crackles or decreased air entry. This assessment helps in evaluating the effectiveness of ventilation and oxygenation. While checking oxygen saturation is important, monitoring lung sounds gives more direct information about the lung involvement in pneumonia. Assessing for cough and fever are also relevant but do not provide as direct and critical information as monitoring lung sounds in the context of suspected pneumonia.