Question

The nurse caring for a client reviews the medical record and determines the client is at risk for developing a potassium deficit because of which situation?

Answer 1

Correct Answers:

Requires nasogastric suction.

Rationale :

🔹 Nasogastric (NG) suction removes gastric secretions rich in electrolytes, especially potassium, predisposing the client to hypokalemia.

🔹 Clients with continuous or intermittent NG suction lose significant amounts of gastric fluid, which contains hydrogen and potassium ions.

🔹 Hypokalemia can result in muscle weakness, cardiac dysrhythmias, and intestinal ileus if not monitored and corrected.

🔹This client is at the highest risk of developing a potassium deficit.

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Answer 2

Correct Answers:

Monitor for muscle paralysis.

Rationale :

🔹 Botulism causes a neurotoxin-mediated neuromuscular blockade, resulting in descending, symmetric paralysis.

🔹 Early symptoms often include blurred vision, dry mouth, and weakness, but paralysis of respiratory muscles can occur rapidly.

🔹 Continuous monitoring for signs of progressive muscle weakness or paralysis, especially in respiratory muscles, is essential.

🔹 The nurse must ensure rapid detection to support airway and ventilatory needs.

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Answer 3

Correct Answers:

Weigh the client before and after the treatment.

Rationale :

✍️ Peritoneal dialysis removes excess fluid, so daily weight is a critical measure of treatment effectiveness.

✍️ Fluid removal is calculated by comparing pre- and post-dialysis weights, helping assess fluid overload or underdialysis.

✍️ Clients should also be assessed for peritonitis, electrolyte shifts, and catheter site integrity, but weight is the most immediate measure.

✍️ Using sterile technique and warming the dialysate are also essential but not the focus of this question.

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Answer 4

Correct Answers:

Herpes zoster

Rationale :

🔹 The zoster vaccine is recommended for adults ≥60 years to prevent shingles and postherpetic neuralgia.

🔹 Shingles risk increases with age due to waning immunity to varicella-zoster virus.

🔹 The vaccine is a preventive measure even for those without known varicella history, as most have been exposed.

🔹 MMR and HPV vaccines are typically not appropriate for this age group unless specific risk factors are identified.

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Answer 5

Correct Answers:

A client who had abdominal surgery 2 days ago and the incision line is separating

Rationale :

👉 Incision separation or wound dehiscence post-surgery is a surgical emergency that may progress to evisceration.

👉 Immediate intervention is required to prevent infection, bleeding, or organ exposure.

👉 This situation takes precedence over chronic or controlled conditions such as pain, tracheostomy care, or C. difficile with expected symptoms.

👉 Rapid notification of the surgical team and appropriate wound care must be implemented.

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Answer 6

Correct Answers:

Oral temperature 39° C (102.2° F)

Rationale :

🔹 A postoperative fever can indicate infection or inflammation, especially within the first 24–48 hours.

🔹 After thyroidectomy, infection is a serious complication that must be addressed immediately.

🔹 While sore throat and minor drainage are common and expected, a fever of 102.2°F (39°C) exceeds the threshold for concern.

🔹 Early detection and treatment can prevent systemic infection or sepsis.

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Answer 7

Correct Answers:

Participate in reminiscence therapy with the client.

Rationale :

🔹 Reminiscence therapy helps clients with Alzheimer’s disease reconnect with past events, improving mood and reducing agitation.

🔹 It enhances communication, memory retrieval, and social interaction.

🔹 Interventions like consistent routines, bright environments, and low-stimulus spaces support cognitive functioning.

🔹 Restraints (four side rails) or changes in routine can worsen confusion and distress.

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Answer 8

Correct Answers:

Apply a motion sensor mat to the client's bed.

Rationale :

🔺 Motion sensor mats provide immediate alerts if a client at risk for falls attempts to leave the bed.

🔺This is especially helpful during night shifts or when supervision is reduced.

🔺 Alternatives like TV or raised side rails are not evidence-based fall prevention strategies and may lead to injury or disorientation.

🔺 Fall prevention in dementia care prioritizes early detection of mobility.

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Answer 9

Correct Answers:

A change in pupil size

Rationale :

🔹 A sudden change in pupil size may indicate increased intracranial pressure (ICP) or brain herniation, which is life-threatening.

🔹 While symptoms like aphasia and right-sided weakness are expected post-left hemispheric stroke, new neuro changes require urgent evaluation.

🔹 The nurse must report this immediately for neurological imaging and intervention.

🔹 Pupil asymmetry may precede deterioration in level of consciousness.

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Answer 10

Correct Answers:

"I will notify emergency response if I have sudden jaw pain."

Rationale :

💧 Jaw pain, especially sudden and unexplained, can be an atypical sign of myocardial infarction (MI).

💧The client must be educated to act immediately by calling EMS and not waiting for chest pain to develop.

💧Statements about waiting or taking four tablets delay necessary intervention.

💧Recognizing early and unusual MI signs can save lives.

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QLexNursing

1 :
The nurse caring for a client reviews the medical record and determines the client is at risk for developing a potassium deficit because of which situation?

2 :
A nurse is assisting with the plan of care for a client who has botulism poisoning. Which of the following interventions should the nurse include in the plan?

3 :
A nurse is assisting with the care of a client who is receiving peritoneal dialysis. Which of the following actions should the nurse take?

4 :
A nurse is collecting data about immunizations from a 65-year-old client who has no identified risk factors for disease. The nurse should identify the client's need for which of the following immunizations?

5 :
A nurse has received change-of-shift report for four clients. Which of the following clients should the nurse attend to first?

6 :
A nurse is caring for a client who is postoperative following a total thyroidectomy for hyperthyroidism. Which of the following findings should the nurse identify as the priority?

7 :
A nurse in a long-term care unit is assisting in the care of a client who has Alzheimer's disease. Which of the following actions should the nurse take?

8 :
A nurse working the night shift is caring for an older adult client who has dementia and is at risk for falls. Which of the following actions should the nurse take?

9 :
A nurse is collecting data from a client who had a left hemispheric stroke. Which of the following findings should the nurse report to the provider immediately?

10 :
A nurse is reinforcing teaching with a client who has angina. Which of the following statements by the client indicates an understanding of the teaching?

QLexNursing

1 : The nurse caring for a client reviews the medical record and determines the client is at risk for developing a potassium deficit because of which situation?

2 : A nurse is assisting with the plan of care for a client who has botulism poisoning. Which of the following interventions should the nurse include in the plan?

3 : A nurse is assisting with the care of a client who is receiving peritoneal dialysis. Which of the following actions should the nurse take?

4 : A nurse is collecting data about immunizations from a 65-year-old client who has no identified risk factors for disease. The nurse should identify the client's need for which of the following immunizations?

5 : A nurse has received change-of-shift report for four clients. Which of the following clients should the nurse attend to first?

6 : A nurse is caring for a client who is postoperative following a total thyroidectomy for hyperthyroidism. Which of the following findings should the nurse identify as the priority?

7 : A nurse in a long-term care unit is assisting in the care of a client who has Alzheimer's disease. Which of the following actions should the nurse take?

8 : A nurse working the night shift is caring for an older adult client who has dementia and is at risk for falls. Which of the following actions should the nurse take?

9 : A nurse is collecting data from a client who had a left hemispheric stroke. Which of the following findings should the nurse report to the provider immediately?

10 : A nurse is reinforcing teaching with a client who has angina. Which of the following statements by the client indicates an understanding of the teaching?

1 :
The nurse caring for a client reviews the medical record and determines the client is at risk for developing a potassium deficit because of which situation?

2 :
A nurse is assisting with the plan of care for a client who has botulism poisoning. Which of the following interventions should the nurse include in the plan?

3 :
A nurse is assisting with the care of a client who is receiving peritoneal dialysis. Which of the following actions should the nurse take?

4 :
A nurse is collecting data about immunizations from a 65-year-old client who has no identified risk factors for disease. The nurse should identify the client's need for which of the following immunizations?

5 :
A nurse has received change-of-shift report for four clients. Which of the following clients should the nurse attend to first?

6 :
A nurse is caring for a client who is postoperative following a total thyroidectomy for hyperthyroidism. Which of the following findings should the nurse identify as the priority?

7 :
A nurse in a long-term care unit is assisting in the care of a client who has Alzheimer's disease. Which of the following actions should the nurse take?

8 :
A nurse working the night shift is caring for an older adult client who has dementia and is at risk for falls. Which of the following actions should the nurse take?

9 :
A nurse is collecting data from a client who had a left hemispheric stroke. Which of the following findings should the nurse report to the provider immediately?

10 :
A nurse is reinforcing teaching with a client who has angina. Which of the following statements by the client indicates an understanding of the teaching?