Nokea
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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The nurse gave Mr. Gary his medication as planned. This is an example of?
- A. Implementation
- B. Planning
- C. Evaluation
- D. Assessment
Correct Answer: A
Rationale: Giving medication as planned is implementation (A) executing care, per process. Planning (B) sets, evaluation (C) assesses, assessment (D) gathers not action-specific. A fits intervention delivery, making it correct.
The nurse assesses a client at 40 weeks gestation and notes regular contractions and cervical dilatation of $6 \mathrm{~cm}$. Which actions by the nurse are important during this stage? Select all that apply.
- A. Administering the epidural injection
- B. Ensuring adequate hydration
- C. Encouraging the client to void
- D. Monitoring the condition of the fetus
Correct Answer: D
Rationale: At 40 weeks gestation with 6 cm cervical dilatation, the client is in active labor. Monitoring the fetus (D) is critical to assess for distress via heart rate patterns, a priority in labor management. Administering an epidural (A) requires an order and isn't universally needed. Ensuring hydration (B) supports labor but isn't the top action. Encouraging voiding (C) prevents bladder distension but is secondary. D is chosen. Rationale: Fetal monitoring detects hypoxia or distress, guiding interventions like position changes or delivery, per ACOG standards, outweighing comfort or supportive measures in immediacy during active labor.
The nurse is caring for a client with a T4 spinal cord injury. Which finding indicates that the client is experiencing neurogenic shock?
- A. Blood pressure 82/40 mm Hg, pulse 48 beats/min
- B. Blood pressure 150/90 mm Hg, pulse 110 beats/min
- C. Blood pressure 110/70 mm Hg, pulse 88 beats/min
- D. Blood pressure 130/80 mm Hg, pulse 62 beats/min
Correct Answer: A
Rationale: Neurogenic shock in T4 SCI features hypotension and bradycardia (A, 82/40, 48 bpm) from sympathetic loss. Hypertension/tachycardia (B) suggests dysreflexia. C and D are normalish. A is correct. Rationale: Loss of vasomotor tone below T4 causes vasodilation and unopposed vagal activity, per SCI pathophysiology, requiring fluids and atropine.
Which of the following urine color is considered normal?
- A. Dark amber
- B. Yellow, Cloudy
- C. Light Yellow, Amber
- D. Slightly pale yellow
Correct Answer: D
Rationale: Slightly pale yellow is normal e.g., hydrated urine per standards. Dark amber (dehydration), yellow cloudy (infection), light yellow amber (concentrated) differ. Nurses assess e.g., hydration for health, per norms.
Which of the following is TRUE about the blood pressure determinants?
- A. Hypervolemia lowers BP
- B. Hypervolemia increases GFR
- C. HCT of 70% might decrease or increase BP
- D. Epinephrine decreases BP
Correct Answer: C
Rationale: HCT 70% e.g., polycythemia can raise BP (viscosity) or lower (poor flow), unlike hypervolemia (raises BP, GFR), or epinephrine (raises). Nurses assess this e.g., anemia for impacts, per dynamics.