Nokea
Which of the following findings would necessitate discontinuing an IV potassium infusion in an adult with ketoacidosis?
- A. Urine output 22 mL/hr for 2 hours
- B. Serum potassium level of 3.7
- C. Small T wave of ECG
- D. Serum glucose level of 180
Correct Answer: A
Rationale: Adequate renal flow of 30 mL/hr is a necessity with potassium infusions because potassium is excreted renally. Because potassium level will decrease during correction of diabetic ketoacidosis, potassium will be infused even if plasma levels of potassium are normal. A small T wave is normal and desired on the electrocardiogram. A tall, peaked T-wave could indicate overinfusion of potassium and hyperkalemia. Glucose levels of <200 are desirable.
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The client is admitted with a diagnosis of molar pregnancy. Which symptom is most likely to be present?
- A. Severe nausea and vomiting
- B. Uterine size smaller than expected
- C. Fetal heart tones at 12 weeks
- D. All of the above
Correct Answer: A
Rationale: Molar pregnancy (hydatidiform mole) often causes severe nausea and vomiting due to high levels of human chorionic gonadotropin (hCG). The uterus is typically larger than expected and fetal heart tones are absent as there is no viable fetus.
The client with a history of diabetes insipidus is admitted with polyuria,polydipsia,and mental confusion. The priority intervention for this client is:
- A. Measuring the urinary output
- B. Checking the vital signs
- C. Encouraging increased fluid intake
- D. Weighing the client
Correct Answer: B
Rationale: Mental confusion in diabetes insipidus may indicate severe dehydration or electrolyte imbalances. Checking vital signs is the priority to assess for instability (e.g. hypotension tachycardia) and guide immediate treatment. The other interventions are secondary.
Which of the following statements reflects Kohlberg's theory of the moral development of the preschool-age child?
- A. Obeying adults is seen as correct behavior.
- B. Showing respect for parents is seen as important.
- C. Pleasing others is viewed as good behavior.
- D. Behavior is determined by consequences.
Correct Answer: D
Rationale: In Kohlberg's preconventional stage (preschool age), morality is based on consequences (punishment or reward). Obeying adults or pleasing others reflects later stages.
What information should the nurse give a new mother regarding the introduction of solid foods for her infant?
- A. Solid foods should not be given until the extrusion reflex disappears at 8-10 months of age.
- B. Solid foods should be introduced one at a time, with 4- to 7-day intervals.
- C. Solid foods can be mixed in a bottle or infant feeder, to make feeding easier.
- D. Solid foods should begin with fruits and vegetables.
Correct Answer: B
Rationale: Introducing solid foods one at a time with 4-7 day intervals allows identification of allergies. The extrusion reflex fades by 4-6 months, and mixing in bottles or starting with fruits is not recommended.
In planning care for the patient with ulcerative colitis, the nurse identifies which nursing diagnosis as a priority?
- A. Anxiety
- B. Impaired skin integrity
- C. Fluid volume deficit
- D. Nutrition altered, less than body requirements
Correct Answer: C
Rationale: Ulcerative colitis causes diarrhea, leading to significant fluid and electrolyte loss, making fluid volume deficit a priority nursing diagnosis to prevent dehydration and shock. Anxiety, skin integrity, and nutrition are secondary concerns.