Nokea
Which of the following electrolytes must be maintained in a steady state for a client receiving lithium?
- A. Sodium
- B. Potassium
- C. Chloride
- D. Magnesium
Correct Answer: A
Rationale: Sodium levels must be stable in clients taking lithium, as fluctuations can affect lithium levels and toxicity risk.
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The parents of a one-month-old boy bring their son to the clinic for evaluation of a possible right dislocated hip.
- A. Which symptom will the nurse observe in a one-month-old with unilateral right hip dislocation?
- B. Limited adduction of the right leg.
- C. Uneven gluteal fold and thigh creases.
- D. Increase in length of the right limb.
- E. Internal rotation of the right leg.
Correct Answer: B
Rationale: Unilateral hip dislocation causes uneven gluteal folds and thigh creases, with deeper and longer folds on the affected side due to hip displacement. Limited abduction (not adduction), shortened limb length, and variable rotation are more typical findings.
An elderly client is oriented during the day but becomes disoriented during the evening.
Which of the following nursing actions is MOST appropriate?
- A. Place a clock where the client can see it.
- B. Restrain all four extremities.
- C. Keep a light on in the client's room.
- D. Place the side rails in an upright position.
Correct Answer: D
Rationale: Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) will provide visual cues, safety is more important (2) inappropriate (3) may be appropriate, but is not priority over answer choice #4 (4) correct-side rails should always be in an upright position for a disoriented client
A pregnant client who is at 34 weeks gestation is diagnosed with a pulmonary embolism (PE). Which of these medications would the nurse anticipate the provider ordering?
- A. Oral Coumadin therapy
- B. Heparin 5000 units subcutaneously B.I.D.
- C. Heparin infusion to maintain the PTT at 1.5-2.5 times the control value
- D. Heparin by subcutaneous injection to maintain the PTT at 1.5 times the control value
Correct Answer: C
Rationale: Heparin infusion to maintain the PTT at 1.5-2.5 times the control value. In pregnant women with pulmonary embolism, heparin is preferred over warfarin due to warfarin's teratogenic effects. A continuous heparin infusion is typically used to achieve therapeutic anticoagulation, monitored by maintaining the PTT at 1.5-2.5 times the control value.
A client is admitted to the trauma intensive care unit (ICU) with a gunshot wound of the neck. The client has a cervical level (C-4) spinal cord injury, is tearful, constantly complains of discomfort, and requests to be suctioned.
The nurse understands that the client's attention-seeking behaviors may be due to
- A. anger and frustration.
- B. awareness of vulnerability.
- C. increased social isolation.
- D. increased sensory stimulation.
Correct Answer: B
Rationale: Strategy: Think about each answer choice. (1) is not accurate for situation (2) correct-is experiencing an increased awareness of his physical vulnerability due to his spinal cord injury; fosters increased dependency needs that are real due to his injury; is trying to determine who is consistent and trustworthy for meeting his significant physical needs (3) is not accurate for situation (4) is not accurate for situation
The nurse is caring for a client with a history of deep vein thrombosis who is receiving warfarin (Coumadin) 5 mg PO daily. Which of the following laboratory results would be of GREATest concern to the nurse?
- A. INR of 3.5.
- B. PTT of 40 seconds.
- C. Platelet count of 200,000/mm^3.
- D. Hemoglobin of 13 g/dL.
Correct Answer: A
Rationale: An INR of 3.5 is above the therapeutic range (2.0–3.0) for DVT, increasing bleeding risk, requiring dose adjustment. Options B, C, and D are normal: PTT is unaffected, platelet count 200,000/mm^3 is adequate, and hemoglobin 13 g/dL is normal.