Nokea
Which organ(s) is/are most at risk for dysfunction in a patient with a potassium level of 6.3 mEq/L?
- A. Lungs
- B. Liver
- C. Kidneys
- D. Heart
Correct Answer: D
Rationale: A potassium level of 6.3 mEq/L indicates hyperkalemia, which can have significant effects on the heart. The heart is one of the most sensitive organs to changes in potassium levels. In hyperkalemia, elevated serum potassium levels can lead to various cardiac manifestations, including dysrhythmias, conduction abnormalities, and eventually cardiac arrest. Monitoring and managing potassium levels are crucial in preventing life-threatening cardiac complications in patients with hyperkalemia. While the kidneys and other organs can also be affected by high potassium levels, the heart is the most critical organ to consider in this scenario.
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Which of the ff is a nursing intervention when assessing clients with hypertension?
- A. The nurse takes the temperature when the client is in a standing, sitting, and then supine position
- B. The nurses teaches the client about non pharmacologic and pharmacologic methods for restoring BP
- C. The nurse takes BP in both arms when the client is in a standing, sitting, and then supine position
- D. The nurse weighs the client each morning
Correct Answer: B
Rationale: The nursing intervention of teaching the client about non-pharmacologic and pharmacologic methods for restoring blood pressure is crucial in managing hypertension. Education empowers the client to actively participate in their care and make informed decisions regarding lifestyle changes, medication adherence, and other interventions to control their blood pressure levels. By providing education on interventions such as dietary modifications, exercise, stress management, and medication use, the nurse helps the client develop a comprehensive plan to manage hypertension effectively and improve their overall health outcomes.
A very popular means of early detection of breast cancer is:
- A. X-ray
- B. Both A and B
- C. Surgical
- D. Breast self examination
Correct Answer: D
Rationale: Breast self-examination (BSE) is a very popular means of early detection of breast cancer as it involves women being aware of how their breasts look and feel to detect any changes such as lumps, swelling, or other abnormalities. By performing regular self-examinations, women can identify any potential issues early on and seek medical advice promptly. While mammograms (X-ray) and clinical breast exams by healthcare providers are also important screening methods for detecting breast cancer, BSE is particularly valuable as women can perform it on a regular basis at home, thus increasing the chances of identifying any concerning changes promptly. It is recommended that women perform BSE monthly to become familiar with their breast tissue and notice any changes over time.
For which of the following problems should the nurse monitor in the patient with multiple myeloma?
- A. Uncontrolled bleeding
- B. Liver engorgement
- C. Respiratory distress
- D. Pathological fractures
Correct Answer: A
Rationale: Patients with multiple myeloma are at an increased risk of bleeding due to low levels of platelets, which play a key role in blood clotting. Uncontrolled bleeding can occur in multiple myeloma patients, leading to serious complications such as hemorrhage and anemia. Therefore, the nurse should monitor for signs of bleeding, such as easy bruising, petechiae, or prolonged bleeding from minor cuts or procedures, and take appropriate interventions to manage and prevent further bleeding episodes in the patient with multiple myeloma. Monitoring for and addressing uncontrolled bleeding is crucial in ensuring the safety and well-being of the patient.
When evaluating the effectiveness of nursing interventions for sinusitis discomfort, which of the following does the nurse assess?
- A. WBC count
- B. Capillary refill
- C. Amount and color of sinus drainage
- D. Comfort level
Correct Answer: C
Rationale: When evaluating the effectiveness of nursing interventions for sinusitis discomfort, assessing the amount and color of sinus drainage is crucial. Changes in these aspects can provide valuable information about the progression of the sinusitis and the effectiveness of the interventions being implemented. Increased or purulent sinus drainage can indicate infection or inflammation, while clearer drainage may suggest improvement. Monitoring these parameters helps the nurse make informed decisions about continuing, modifying, or discontinuing interventions to manage the patient's sinusitis discomfort effectively. Evaluating WBC count, capillary refill, and comfort level are also important assessments in certain situations, but assessing the amount and color of sinus drainage is most directly related to sinusitis symptoms.
What are the signs of organ rejection a nurse should closely monitor for when caring for a client after heart transplantation? Choose all that apply
- A. Low white blood cell count
- B. Dyspnea
- C. ECG changes
- D. Fever
Correct Answer: A
Rationale: When caring for a client after heart transplantation, the signs of organ rejection that a nurse should closely monitor for include low white blood cell count and dyspnea.