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Questions 164

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Extract:

Laboratory reference ranges
Potassium3.5-5.0 mEq/L(3.5-5.0 mmol/L)
INRNormal: 0.8-1.1Therapeutic: 1.5-4.0


Question 1 of 5

The nurse recognizes which of the following factors as possibly contributing to a sentinel event?

Correct Answer: A

Rationale: Administering warfarin with an INR of 6.0 (therapeutic range 2.0-3.0) risks severe bleeding, a sentinel event. Flumazenil is appropriate for lorazepam overdose, nitroprusside for hypertensive crisis, and insulin/dextrose for hyperkalemia are correct interventions.

Extract:


Question 2 of 5

The nurse is caring for a client hospitalized with bipolar disorder, manic phase who is taking Eskalith (lithium carbonate). Which of the following snacks would be best for the client?

Correct Answer: C

Rationale: Lithium carbonate can cause sodium depletion, and high-sodium snacks like potato chips should be avoided to prevent toxicity. Diet cola lacks nutritional value and may contain caffeine, which can exacerbate mania. An apple is a healthy, low-sodium snack that supports hydration and nutrition. A milkshake may be high in sugar or fat, which is less ideal.

Question 3 of 5

The nurse is reinforcing meal planning teaching to a group of clients with celiac disease. Which meal is appropriate for the nurse to include?

Correct Answer: C

Rationale: Grilled chicken, green beans, and mashed potatoes are gluten-free, suitable for celiac disease. Dinner rolls, breaded pork chops, and spaghetti contain gluten, which must be avoided.

Question 4 of 5

The nurse reinforces teaching to a parent of a 2-month-old client regarding administration of an oral liquid medication. The nurse knows that the parent understands the teaching when the parent performs which action?

Correct Answer: A

Rationale: Administering small amounts at the back of the cheek with a syringe ensures safe delivery and reduces choking risk in a 2-month-old. Cups, tongue administration, and mixing with formula are unsafe or ineffective.

Question 5 of 5

The nurse is assessing a client with delayed wound healing. Which of the following risk factors is most important in this situation?

Correct Answer: C

Rationale: Long term steroid usage. Steroids delay wound healing by impairing the inflammatory response.

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