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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. How should a healthcare provider assess a patient for fluid overload?
- A. Monitor weight and assess for shortness of breath
- B. Auscultate lung sounds and monitor blood pressure
- C. Assess for edema in the extremities
- D. Assess for jugular venous distension
Correct answer: A
Rationale: Correctly, the answer is to monitor weight and assess for shortness of breath when assessing a patient for fluid overload. Weight monitoring is crucial as sudden weight gain can indicate fluid retention. Shortness of breath can be a sign of fluid accumulation in the lungs. While auscultating lung sounds and monitoring blood pressure are important assessments in overall patient care, they may not be specific to fluid overload. Assessing for edema in the extremities is relevant, but it is not as sensitive as monitoring weight for detecting fluid overload. Assessing for jugular venous distension is more specific to assessing fluid status in heart failure rather than a general assessment for fluid overload.
3. A client has a prescription for ciprofloxacin. Which of the following instructions should the nurse include?
- A. Take the medication with an antacid if you experience gastrointestinal upset.
- B. You should limit your caffeine intake while taking this medication.
- C. This medication may cause your urine to turn dark brown.
- D. You should avoid taking this medication with dairy products.
Correct answer: D
Rationale: The correct answer is D: 'You should avoid taking this medication with dairy products.' Ciprofloxacin should not be taken with dairy products as they can interfere with the absorption of the medication. Choice A is incorrect because ciprofloxacin should not be taken with antacids containing aluminum or magnesium. Choice B is incorrect as there is no specific limitation on caffeine intake associated with ciprofloxacin. Choice C is incorrect as ciprofloxacin does not typically cause urine to turn dark brown.
4. A nurse is contributing to an in-service for newly-licensed nurses about child maltreatment. The nurse should include that which of the following characteristics increases a child's risk of physical maltreatment?
- A. Low birth weight
- B. Advanced maternal age
- C. Single parenthood
- D. Premature birth
Correct answer: A
Rationale: Low birth weight increases a child's vulnerability to physical maltreatment due to additional care needs. Advanced maternal age (choice B) is not directly linked to an increased risk of physical maltreatment. Single parenthood (choice C) is not a characteristic that inherently increases the risk of physical maltreatment. Premature birth (choice D) is not listed as a characteristic that directly increases a child's risk of physical maltreatment.
5. A nurse is reinforcing teaching about food selection with a client who has a moderate burn injury. Which of the following foods should the nurse recommend as being high in vitamin C?
- A. Tomatoes
- B. Carrots
- C. Avocados
- D. Apricots
Correct answer: A
Rationale: Tomatoes are high in vitamin C, which is crucial for wound healing, making them an excellent recommendation for a client with a burn injury. Carrots, avocados, and apricots are not as rich in vitamin C compared to tomatoes, and therefore, they are not the best choice for promoting healing in this scenario.
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