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A nurse is caring for a client with DI. Which data warrants the most
immediate intervention by the nurse? Rationale:The most immediate
concern is **serum sodium of 185** (option a). A sodium level this high
indicates severe hypernatremia, which can be life-threatening and
requires urgent treatment.
a. Serum sodium of 185
b. Dry skin with inelastic turgor
c. Apical rate of 110 beats per minute
d. Polyuria and excessive thirst
Ans: a. Serum sodium of 185
Quiz: The nurse is obtaining the admission history for a client with
suspected peptic ulcer disease (PUD). Which subjective data reported
by the client supports this medical diagnosis? Rationale:This type of
pain is characteristic of PUD, as it often occurs in the upper abdomen
and is described as gnawing, burning, or hunger-like, typically
worsened by an empty stomach and relieved by eating or antacids.
a. Frequent use of chewable and liquid antacids for indigestion
,b. severe abdominal cramps and diarrhea after eating spicy foods
c. upper mid-abdominal pain described as gnawing and burning.
d. Marked loss of weight and appetite over the last 3 or 4 months
Ans: c. upper mid-abdominal pain described as gnawing and burning.
Quiz: The nurse assess a client who is newly diagnosed with
hyperthyroidism and observes that the client's eyeballs are protuberant,
causing a wide-eyed appearance and eye discomfort. Based on this
finding, which action should the nurse include in this client's plan of
care? Rationale:The client's symptoms—protuberant eyeballs
(exophthalmos) and eye discomfort—are characteristic of Graves'
disease, a common cause of hyperthyroidism. Exophthalmos can lead
to dryness and irritation of the eyes, and artificial tear drops can help
relieve discomfort and protect the corneas from damage due to
decreased eyelid closure.
a. Assess for signs of increased intracranial pressure
b. Prepare to administer intravenous levothyroxine
c. Review the client's serum electrolyte values
d. Obtain a prescription for artificial tear drops
Ans: d. Obtain a prescription for artificial tear drops
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,Quiz: To reduce the risk for pulmonary complication for a client with
Amyotrophic Lateral Sclerosis (ALS), which interventions should the
nurse implement? (Select all)
a. Perform chest physiotherapy
b. Teach the client breathing exercises
c. Initiate passive range of motion exercises
d. Establish a regular bladder routine
e. Encourage use of incentive spirometer
Ans: a. Perform chest physiotherapy
b. Teach the client breathing exercises
e. Encourage use of incentive spriometer
Quiz: A client hospitalized with heart failure (HF). Which intervention
should the nurse implement to improve ventilation and reduce venous
return? Rationale:Placing the client in high Fowler position helps by
improving lung expansion, easing breathing, and reducing venous
return to the heart, which relieves symptoms like shortness of breath in
heart failure.
a. Perform passive range of motion exercises
b. Place the client in high fowler position
c. Administer oxygen per nasal canula
d. Increase the client's activity level
Ans: b. Place the client in high fowler position
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, Quiz: A client who was involved in a motor vehicle collision is admitted
with a fractured left femur which is immobilized using a fracture traction
splint in preparation for an open reduction internal fixation (ORIF). The
nurse determines that the client's distal pulses are diminished in the left
foot. Which interventions should the nurse implement? (select all)
a. Verify pedal pulses using a doppler pulse device
b. Evaluate the application of the splint to the left leg.
c. Offer ice chips and oral clear liquids.
d. Monitor left leg for pain, pallor, paresthesia, paralysis, pressure
3. Administer oral antispasmodics and narcotic analgesics
Ans: Verify pedal pulses using a Doppler pulse device,Evaluate the
application of the splint to the left leg,Monitor left leg for pain, pallor,
paresthesia, paralysis, pressure
Quiz: The healthcare provider prescribes diagnostic tests for a client
whose chest X-ray indicates pneumonia. Which diagnostic test should
the nurse review for implementation in the most therapeutic treatment
of the pneumonia? Rationale:test identifies the specific microorganism
causing the pneumonia and helps determine the most effective
antibiotic or antimicrobial treatment
a. Sputum culture and sensitivity
b. Blood cultures
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