NCLEX Review - Fundamentals of Nursing 7th edition
a) the client fell out of bed
b) the client climbed over the side rails
c) the client was found lying on the floor
d) the client became restless and tried to get out of bed
27. A client is brought to the emergency room by emergency medical services (EMS) after being hit by a car. The name of the client is not known and the client has sustained a severe head injury and multiple fractures, and unconscious. An emergency craniotomy is required. Regarding informed consent for the surgical procedure, which of the following is the best action?
a) obtain a court order for the surgical procedure
b) transport the victim to the operating room for surgery
c) call the police to identify the client and locate the family
d) ask the EMS team to sign the informed consent
28. A nurse is reading a physician's progress notes in the client's record and reads that the physician has documented "insensible fluid loss of approximately 800 ml daily." The nurse understands that this type of fluid loss can occur through:
a) the skin
b) urinary output
c) wound drainage
d) the gastrointestinal tract
29. A nurse instructs a client at risk for hypokalemia about the foods high in potassium that should be included in the daily diet. The nurse determines that the client understands the food sources of potassium if the client states that the food item lowest in potassium is:
a) apples
b) carrots
c) spinach
d) avocado
30. A nurse caring for a group of clients reviews the electrolyte laboratory results and notes a potassium level of 5.5 mEq/L on one client's laboratory report. The nurse understands that which client is at highest risk for the development of a potassium value at this level?
a) the client with colitis
b) the client with cushing's syndrome
c) the client who has been overusing laxatives
d) the client who has sustained a traumatic burn
Fundamentals of Nursing 7th edition:
ANSWERS AND RATIONALE
26) C
- The incident report should contain the client’s name, age, and diagnosis. The report should contain a factual description of the incident, any injuries experienced by those involved, and the outcome of the situation. Option 3 is the only option that describes the facts as observed by the nurse. Options A, B, and D are interpretations of the situation and are not factual information as observed by the nurse.27) B
- Generally, there are two situations in which informed consent of an adult client is not needed. One is when an emergency is present and delaying treatment for the purpose of obtaining informed consent would result in injury or death to the client. The second is when the client waives the right to give informed consent. Option A will delay emergency treatment and option D is inappropriate. Although option C may be pursued, it is not the best action.28) A
- Sensible losses are those of which the person is aware, such as through wound drainage, gastrointestinal tract losses, and urination. Insensible losses may occur without the person’s awareness. Insensible losses occur daily through the skin and the lungs.29) A
- A medium apple provides about 159 mg of potassium. A large carrot provides 341 mg, spinach (3½ oz) provides 470 mg, and a medium avocado provides 1097 mg of potassium.30) D
A serum potassium level higher than 5.1 mEq/L indicates hyperkalemia. Clients who experience cellular shifting of potassium in the early stages of massive cell destruction, such as with trauma, burns, sepsis, or metabolic or respiratory acidosis, are at risk for hyperkalemia. The client with Cushing’s syndrome or colitis and the client who has been overusing laxatives are at risk for hypokalemia.Go to the next page ---> Fundamentals of Nursing 7th edition (31-35)
Or go back to Fundamentals of Nursing 7th edition (1-5)
Related Topics:
Posts
0 comments:
Post a Comment