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1. A nurse is caring for a client who has been diagnosed with hyperkalemia. Which of the following findings should the nurse expect?
- A. Muscle weakness
- B. Nausea
- C. Increased thirst
- D. Restlessness
Correct answer: A
Rationale: Muscle weakness is a characteristic finding in hyperkalemia. High levels of potassium can affect the normal function of muscles, leading to weakness. Nausea and increased thirst are not typically associated with hyperkalemia. Restlessness is more commonly seen in conditions such as hypoxia or anxiety, not specifically in hyperkalemia.
2. What lifestyle change should be emphasized for a client with hypertension?
- A. Increase intake of dairy products
- B. Reduce caffeine and sodium intake
- C. Eat carbohydrate-rich meals
- D. Limit intake of leafy green vegetables
Correct answer: B
Rationale: The correct lifestyle change that should be emphasized for a client with hypertension is to reduce caffeine and sodium intake. Caffeine can temporarily raise blood pressure, and high sodium intake is linked to increased blood pressure levels. Therefore, reducing these two components can help manage blood pressure in individuals with hypertension. Choices A, C, and D are incorrect because increasing intake of dairy products, consuming carbohydrate-rich meals, and limiting intake of leafy green vegetables do not specifically address the factors that contribute to high blood pressure in hypertension.
3. A nurse is assisting with performing a nonstress test for a client who is at 39 weeks of gestation. Which of the following instructions should the nurse reinforce with the client?
- A. Do not press the button during baby's movements
- B. You should depress the button when you feel your baby move
- C. Press the button only during contractions
- D. Do not eat before the test
Correct answer: B
Rationale: The correct answer is B because the client should press the button when feeling fetal movement to track the baby's activity. Choice A is incorrect because the client should press the button during movements. Choice C is incorrect as the button should be pressed during fetal movements, not contractions. Choice D is irrelevant to the instructions for the nonstress test.
4. What is the priority nursing action for a client with dehydration?
- A. Administer oral fluids
- B. Monitor electrolyte levels
- C. Administer antiemetics as needed
- D. Encourage bed rest
Correct answer: B
Rationale: The priority nursing action for a client with dehydration is to monitor electrolyte levels. Dehydration can cause imbalances in electrolytes such as sodium and potassium, affecting essential bodily functions. Monitoring electrolyte levels is crucial to promptly identify and correct any imbalances. While administering oral fluids (Choice A) is vital in treating dehydration, monitoring electrolyte levels takes precedence as it directly addresses the underlying imbalance. Administering antiemetics (Choice C) may be necessary for nausea and vomiting but is not the priority over electrolyte monitoring. Encouraging bed rest (Choice D) can conserve energy but is not as critical as monitoring electrolyte levels to prevent complications related to electrolyte imbalances.
5. A nurse is reinforcing teaching about home care for conjunctivitis with the parent of a school-age child. Which of the following information should the nurse include?
- A. Use a separate washcloth for the child
- B. Apply cold compresses to the eyes
- C. Apply warm compresses to the eyes
- D. Keep the child home until symptoms have resolved
Correct answer: A
Rationale: The correct answer is to use a separate washcloth for the child. This is important to prevent the spread of infection when a child has conjunctivitis. Using the same washcloth can lead to cross-contamination and further spread of the condition. Applying cold or warm compresses may provide comfort but do not address the prevention of spreading the infection. Keeping the child home until symptoms have resolved may be necessary, but the primary focus should be on preventing the spread of the infection within the household.
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