Nokea
Which of the following imbalances should the nurse check for in a pregnant client with hypertension and cardiac dysrhythmias?
- A. Metabolic acidosis
- B. Hypomagnesemia
- C. Hypernatremia
- D. Hypercalcemia
Correct Answer: B
Rationale: Hypomagnesemia is commonly associated with pregnancy-induced hypertension and can contribute to cardiac dysrhythmias. Magnesium plays a critical role in neuromuscular function and electrolyte balance.
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You are the charge nurse. Which client is most appropriate to assign to the step-down unit nurse pulled to the intensive care unit for the day?
- A. A 68-year-old client on ventilator with acute respiratory failure and respiratory acidosis
- B. A 72-year-old client with COPD and normal arterial blood gases (ABGs) who is ventilator-dependent
- C. A 56-year-old new admission client with diabetic ketoacidosis (DKA) on an insulin drip
- D. A 38-year-old client on a ventilator with narcotic overdose and respiratory alkalosis
Correct Answer: B
Rationale: A client with stable ABGs and ventilator dependence is less complex compared to other options, making them suitable for a step-down nurse temporarily working in ICU.
A client develops volume overload from an IV that has infused too rapidly. What assessment would the nurse expect to find?
- A. S3 heart sound.
- B. Thready pulse.
- C. Flattened neck veins.
- D. Hypoventilation.
Correct Answer: A
Rationale: An S3 heart sound indicates volume overload.
What is the priority intervention for a patient admitted to your unit diagnosed with advanced amyotrophic lateral sclerosis (ALS)?
- A. Develop a method of communication.
- B. Provide six small meals high in protein and assist with feeding.
- C. Do not involve the patient in decisions about his healthcare because he is not in the mental state to respond.
- D. Provide six normal meals high in protein and assist with feeding.
Correct Answer: A
Rationale: Communication becomes critical as ALS progresses and affects motor functions.
A male client has returned to the Unit following a left femoral popliteal bypass graft. Six hours later, the client's dorsalis pedis pulse cannot be palpated and his foot is cool and dusky. The nurse should:
- A. continue to monitor the foot.
- B. immediately notify the physician.
- C. notify the head nurse.
- D. assure the client that his foot is fine.
Correct Answer: B
Rationale: The client is losing the blood supply to his left foot. Continuing to monitor will not restore the blood supply to the foot. The physician should be notified immediately because the client is losing the blood supply to his left foot and is in danger of losing his foot and/or his leg. It is the responsibility of the nurse caring for the client to notify the physician, not the head nurse. This would be giving the client false assurances, which is unethical, demeaning, and could have legal consequences.
Mary is diagnosed with a brain tumor and is unable to speak. Where is the tumor probably located?
- A. Occipital lobe.
- B. Cerebellum.
- C. Frontal lobe.
- D. Parietal lobe.
Correct Answer: C
Rationale: The frontal lobe controls speech and language functions.