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Questions 164

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Question 1 of 5

The nurse is observing a staff member perform ear irrigation for an adult client with impacted cerumen. The nurse should intervene if the staff member is observed

Correct Answer: C

Rationale: Pulling the pinna down and back is incorrect for adults; it should be up and back. Slow flow , head tilt , and directing solution upward are correct.

Question 2 of 5

The nurse is caring for a client with left-sided weakness from a stroke. When assisting the client to a chair, what should the nurse do?

Correct Answer: D

Rationale: A transfer belt ensures safety during transfers. Bending at the waist , close feet , and pivoting increase fall risk.

Question 3 of 5

A client, admitted to the unit because of severe depression and suicidal threats, is placed on suicidal precautions. The nurse should be aware that the danger of the client committing suicide is greatest

Correct Answer: B

Rationale: Suicide potential is often increased when there is an improvement in mood and energy level. At this time ambivalence is often decreased and a decision is made to commit suicide.

Question 4 of 5

A client is taking lithium for management of bipolar I disorder. The client's most recent serum lithium level is 0.8 mEq/L (0.8 mmol/L). Based on this result, what prescription does the nurse anticipate receiving from the health care provider?

Correct Answer: D

Rationale: A lithium level of 0.8 mEq/L is low (therapeutic range: 1.0-1.5 mEq/L for acute mania). Increasing the dose is likely to achieve therapeutic levels.

Question 5 of 5

A client with hyperkalemia is to receive an infusion of $250 \mathrm{~mL}$ of $20% glucose with 20 units of regular insulin. The rationale for this therapy is:

Correct Answer: C

Rationale: Insulin facilitates glucose uptake by cells, which drives potassium into cells, lowering serum potassium levels in hyperkalemia.

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