Nokea
Which of the following lab values might the nurse expect to see in a client with Addison's disease?
- A. WBC 10,000
- B. BUN 22
- C. $\mathrm{K}+3.5 \mathrm{mEq} / \mathrm{L}$
- D. $\mathrm{Na}+142 \mathrm{mEq} / \mathrm{L}$
Correct Answer: C
Rationale: Addison's disease causes hyperkalemia (elevated potassium, not 3.5 mEq/L, which is normal) and hyponatremia due to adrenal insufficiency.
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The nurse observes a LPN/LVN perform a wet-to-dry dressing change on a 2-inch abdominal incision.
- A. Which behavior by the LPN/LVN indicates proper wet-to-dry dressing change technique?
- B. A clean cotton ball is used to cleanse from the top of the incision to the bottom of the incision using long strokes.
- C. The incision is packed with sterile gauze, and then sterile saline is poured over the dressing.
- D. The nurse packs wet gauze into the incision without overlapping it onto the skin.
- E. The old dressing is saturated with sterile saline before it is removed.
Correct Answer: C
Rationale: Packing wet gauze into the incision without overlapping onto the skin prevents skin breakdown from prolonged moisture exposure. Cleansing should be from the center outward, dressings should be pre-soaked, and old dressings are removed dry to debride the wound.
The nurse is caring for a client with a history of diabetic ketoacidosis.
- A. Which intervention is most important for a client with diabetic ketoacidosis?
- B. Administer insulin as ordered.
- C. Restrict all oral fluids.
- D. Administer oral glucose.
- E. Monitor blood pressure every 4 hours.
Correct Answer: A
Rationale: Insulin administration corrects hyperglycemia and ketosis in diabetic ketoacidosis, the primary treatment. IV fluids are used, oral glucose is contraindicated, and blood pressure monitoring is less frequent.
A disoriented male client reveals that the client has a self-care deficit (feeding).
Which of the following would indicate to the nurse that the client has made a positive response to the plan of care?
- A. Client explains the relationship between weight loss and change in mental status.
- B. Client identifies the basic four food groups.
- C. Client states he needs to drink more water.
- D. Client feeds self when the nurse stays with him and cues him.
Correct Answer: D
Rationale: Strategy: Determine the outcome of each answer choice. (1) would not be realistic in a client who is disoriented (2) would not be realistic in a client who is disoriented (3) would not be realistic in a client who is disoriented (4) correct-disoriented client who is not able to be an independent self-care agent will need cuing from the nurse to accomplish self-feeding
A client is admitted with acute abdominal pain. Which of the following findings would require immediate attention?
- A. BP 100/50, P 96, abdominal distention
- B. Temperature 99°, flatulence, nausea
- C. Urinary frequency and dysuria
- D. Temperature 99.2°, amber-colored urine
Correct Answer: A
Rationale: Hypotension (BP 100/50), tachycardia (P 96), and abdominal distention suggest a serious condition like internal bleeding or perforation, requiring immediate attention.
The nurse is teaching a client with a new diagnosis of asthma about fluticasone (Flovent). Which of the following statements by the client indicates a need for further teaching?
- A. I should rinse my mouth after using this inhaler.
- B. I should use this inhaler twice a day.
- C. I should report a sore throat to my doctor.
- D. I should use this inhaler when I have trouble breathing.
Correct Answer: D
Rationale: Using fluticasone as a rescue inhaler is incorrect, as it is a corticosteroid for maintenance therapy, not acute symptoms. Options A, B, and C are correct: rinsing prevents oral thrush, twice-daily use is standard, and sore throat may indicate infection.