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Which of the following condition has an increased risk of for developing hyperkalemia?
- A. Crohn's disease
- B. Cushing's disease
- C. Chronic heart failure
- D. End-stage renal disease
Correct Answer: D
Rationale: End-stage renal disease impairs potassium excretion, causing hyperkalemia as kidneys fail to filter excess. Crohn's affects absorption, Cushing's alters cortisol, and heart failure impacts circulation not potassium directly. Nurses monitor levels in renal patients, adjusting diet or dialysis to prevent arrhythmias or muscle issues from high potassium, a common complication.
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Which of the following assessment finding is typical of extracellular fluid loss?
- A. Distended jugular veins
- B. Elevated hematocrit level
- C. Rapid thready pulse
- D. Increased serum sodium level
Correct Answer: C
Rationale: Extracellular fluid loss (e.g., dehydration) reduces blood volume, causing a rapid, thready pulse as the heart compensates for hypovolemia. Distended jugular veins suggest fluid overload, not loss. Elevated hematocrit reflects hemoconcentration, but pulse is a more immediate sign. Increased sodium occurs with water loss, not always fluid volume. Nurses monitor pulse to detect early shock, guiding fluid replacement to restore circulation and prevent organ damage.
Mr. Gary uses acupuncture along with his meds. This is an example of?
- A. Complementary therapy
- B. Alternative therapy
- C. Therapeutic touch
- D. Health promotion
Correct Answer: A
Rationale: Acupuncture with meds is complementary therapy (A) with conventional, per definition. Alternative (B) replaces, touch (C) hands, promotion (D) well-being not combo-specific. A fits integrated use, making it correct.
A 46-year-old female with chronic constipation is assessed by the nurse for a bowel training regimen. Which factor indicates further information is needed by the nurse?
- A. The client's dietary habits include foods high in bulk
- B. The client's fluid intake is between 2500-3000 ml per day
- C. The client engages in moderate exercise each day
- D. The client's bowel habits were not discussed
Correct Answer: D
Rationale: Bowel habits are essential to tailor a training regimen; their absence indicates a gap.
The nurse is caring for a client following a transurethral resection of the prostate (TURP). Which finding should be reported to the physician immediately?
- A. Bright red urine 12 hours post-op
- B. Urine output of 30 mL/hour
- C. Complaints of bladder spasms
- D. Temperature of 100.2°F
Correct Answer: A
Rationale: Bright red urine 12 hours post-TURP suggests active bleeding, abnormal beyond initial pink-tinged output, requiring immediate physician report low output, spasms, or mild fever are less urgent. Nurses flag this, as hemorrhage risks clot retention or shock, prompting irrigation or intervention.
The nurse adapted care to Mr. Gary's cultural diet. This is an example of?
- A. Cultural competence
- B. Trust
- C. Health promotion
- D. Nursing informatics
Correct Answer: A
Rationale: Adapting to cultural diet is cultural competence (A) diversity respect, per definition. Trust (B) bond, promotion (C) well-being, informatics (D) tech not culture-specific. A fits the nurse's sensitivity to Mr. Gary's needs, making it correct.