An adult who has gastroenteritis and is on digitalis ha lab values of: K 3.2 mEq/L, Na 136 mEq/L, Ca 8.8 mg/dl, and Cl 98 mEq/L. the nurse puts which of the following on the client's plan of care?

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Question 1 of 5

An adult who has gastroenteritis and is on digitalis ha lab values of: K 3.2 mEq/L, Na 136 mEq/L, Ca 8.8 mg/dl, and Cl 98 mEq/L. the nurse puts which of the following on the client's plan of care?

Correct Answer: C

Rationale: The client's low potassium level (K 3.2 mEq/L) is a cause for concern, especially in a patient on digitalis therapy. Digitalis (such as digoxin) can potentiate the effects of hypokalemia, leading to an increased risk of digitalis toxicity. Therefore, in this scenario, it is important to avoid foods rich in potassium to prevent further lowering of the potassium level. It is essential to address the electrolyte imbalance promptly to prevent potential complications related to digitalis therapy.

Question 2 of 5

A postpartum nurse is providing instructions to the mother of a newborn infant with hyperbilirubinemia who is being breastfed. The nurse provides which most appropriate instructions to the mother?

Correct Answer: D

Rationale: The most appropriate instruction for a mother of a newborn infant with hyperbilirubinemia who is being breastfed is to continue to breastfeed every 2-4 hours. Breastfeeding should be initiated within 2 hours after birth and continued every 2-4 hours thereafter. Breast milk helps to promote the passage of meconium (the dark green stools of the newborn) and reduce the risk of hyperbilirubinemia. It is important to continue breastfeeding to establish and maintain a good milk supply, promote bonding between mother and baby, and provide important nutrients to the newborn. Switching to bottle feeding or feeding the newborn infant less frequently is not recommended in this case.

Question 3 of 5

When teaching umbilical cord care to a new mother, the nurse would include which information?

Correct Answer: C

Rationale: Keeping the cord dry and open to air is the recommended practice for umbilical cord care. This helps the cord to dry out and fall off naturally. Applying substances like peroxide or petroleum jelly can create a moist environment, which can increase the risk of infection. Washing the cord with soap and water daily can also prolong the time it takes for the cord to fall off. Thus, the best approach is to simply keep the cord clean and dry, allowing it to heal and detach on its own.

Question 4 of 5

Parents bring their infant to the clinic, seeking treatment for vomiting and diarrhea that has lasted for 2 days. On assessment, the nurse in charge detects dry mucous membranes and lethargy. What other findings suggests a fluid volume deficit?

Correct Answer: A

Rationale: A sunken fontanel is a classic sign of dehydration in infants. When a child is experiencing fluid volume deficit, the body's priority is to maintain blood flow to vital organs, resulting in decreased blood circulation to the skin and extremities. Consequently, decreased skin turgor and a sunken fontanel are common manifestations of dehydration. Other signs of fluid volume deficit may include dry mucous membranes, lethargy, decreased urine output, and increased heart rate.

Question 5 of 5

7-year-old Damon has cystitis; which of the following would Nurse Elena expect when assessing the child?

Correct Answer: A

Rationale: Cystitis is inflammation of the bladder, commonly caused by a bacterial infection. In children, symptoms of cystitis often include dysuria, which is painful or difficult urination. This symptom is frequently observed in children with cystitis. Costovertebral tenderness and flank pain are more indicative of kidney involvement (such as in pyelonephritis) rather than just bladder inflammation like in cystitis. High fever may also be present in severe cases of cystitis, but dysuria is the more specific and common symptom associated with this condition in children.

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