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Questions 158

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Question 1 of 5

A client has renal failure. Today's lab values indicate he has an elevated serum potassium. What additional priority information does the nurse need to obtain?

Correct Answer: B

Rationale: The level of consciousness is not affected by elevated potassium levels. An electrocardiogram (EKG) can tell the nurse whether this client is experiencing any cardiac dysfunction or arrhythmias related to the elevated potassium level. Measurement of the urine output is not a priority nursing action at this time. The client's serum potassium values for the past several days may provide information about his renal function, but they are not a priority at this time.

Question 2 of 5

A five-month-old infant is admitted to the ER with a temperature of 103.6°F and irritability. The mother states that the child has been listless for the past several hours and that he had a seizure on the way to the hospital. A lumbar puncture confirms a diagnosis of bacterial meningitis. The nurse should assess the infant for:

Correct Answer: B

Rationale: Tenseness of the anterior fontanel indicates increased intracranial pressure in bacterial meningitis due to inflammation. The other findings are not specific to meningitis in infants.

Question 3 of 5

A 32-year-old female client is being treated for Guillain-Barré syndrome. She complains of gradually increasing muscle weakness over the past several days. She has noticed an increased difficulty in ambulating and fell yesterday. When conducting a nursing assessment, which finding would indicate a need for immediate further evaluation?

Correct Answer: C

Rationale: Headaches are not associated with Guillain-Barré syndrome. Loss of superficial and deep tendon reflexes is expected with this diagnosis. Complaints of shortness of breath must be further evaluated. Forty percent of all clients have some detectable respiratory weakness and should be prepared for a possible tracheostomy. Pneumonia is also a common complication of this syndrome. Facial paralysis is expected and is not considered abnormal.

Question 4 of 5

The nurse is caring for a client with pneumonia who is allergic to penicillin. Which antibiotic is safest to administer to this client?

Correct Answer: C

Rationale: Erythromycin, a macrolide, is safe for penicillin-allergic patients. Cefazolin (
A), Amoxicillin (
B), and Ceftriaxone (
D) are beta-lactams with cross-reactivity risks.

Question 5 of 5

A patient refuses to take his dose of oral medication. The nurse tells the patient that if he does not take the medication that she will administer it by injection. The nurse's comments can result in a charge of:

Correct Answer: B

Rationale: Threatening to administer medication by injection against the patient's will constitutes assault, as it involves a threat of unwanted contact.

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