A nurse is assisting in the care of a female client.

Complete the following sentence by using the lists of options.

The nurse should first address the client
.......
followed by the client's
.....
.

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}

Blood pressure. The client's blood pressure dropped from 104/56 mm Hg to 80/46 mm Hg, indicating worsening hypotension. This suggests fluid volume depletion due to ongoing diarrhea and possible sepsis from Clostridium difficile infection. Hypotension is the priority concern as it can lead to shock and organ dysfunction if not addressed immediately. The nurse should anticipate fluid resuscitation with IV fluids to restore circulatory volume.
Hgb level. The client's hemoglobin is 17 g/dL, which is elevated compared to normal values (12-16 g/dL). This suggests hemoconcentration, likely due to dehydration from severe diarrhea rather than an actual increase in red blood cell count. While this is concerning, the immediate priority is addressing hypotension before evaluating hemoglobin further.
Temperature. The client has a persistent fever of 38.9°C (102°F), which indicates an active Clostridium difficile infection. While fever management is important, hypotension takes priority because it can lead to hypoperfusion and organ failure. Antipyretic medications and infection control measures can be initiated after stabilizing blood pressure.
Potassium level. The client's potassium is 3.1 mEq/L, which is below the normal range (3.5-5.0 mEq/L). Diarrhea leads to potassium loss, increasing the risk of cardiac arrhythmias and muscle weakness. After stabilizing the client’s blood pressure, potassium replacement is critical to prevent life-threatening hypokalemia-related complications such as cardiac dysrhythmias.
Abdominal findings. The client has a soft, distended abdomen with hyperactive bowel sounds and watery stools with mucus, consistent with Clostridium difficile infection. While these findings confirm the diagnosis, the more urgent issues of hypotension and electrolyte imbalances must be addressed first before further gastrointestinal assessment.
Hct level. The hematocrit is elevated (48%), which aligns with hemoconcentration from dehydration. However, fluid resuscitation will help correct this, making it a secondary concern after addressing blood pressure and potassium levels.

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Correct Answer is B

Explanation

A. Assist the client to a left lateral position. The preferred position for vaginal suppository insertion is the dorsal recumbent (lying on the back with knees bent) or the lithotomy position. The left lateral position is typically used for rectal suppository administration, not vaginal medication insertion.

B. Insert the suppository along the posterior wall of the vaginal canal. The suppository should be inserted along the posterior vaginal wall, as this allows for proper absorption and helps ensure the medication remains in place. The client should be advised to lie down for at least 10-15 minutes after insertion to prevent the suppository from slipping out.

C. Apply a light coating of petroleum jelly to the suppository. Petroleum jelly should never be used as it can interfere with medication absorption and may break down the suppository. If lubrication is needed, a small amount of water-soluble lubricant (e.g., KY Jelly) can be applied to facilitate insertion.

D. Put on sterile gloves before handling the suppository. Clean gloves (not sterile gloves) are sufficient for vaginal suppository administration. The vaginal canal is not a sterile environment, so strict aseptic technique is not required. However, proper hand hygiene and glove use are essential to prevent contamination and infection.

A. Increase fluid intake B. Decrease sodium intake C. Eat foods high in potassium D. Take the medication 1 hr before meals.

Correct Answer is A

Explanation

A. Increase fluid intake. Clients taking lithium should increase fluid intake to 2-3 litres per day to prevent dehydration and maintain proper lithium excretion. Lithium is excreted by the kidneys, and dehydration can lead to toxic accumulation in the body. Adequate hydration also helps reduce the risk of side effects such as nephrotoxicity and lithium-induced polyuria.

B. Decrease sodium intake. Clients should not decrease sodium intake while on lithium. A low-sodium diet increases lithium reabsorption in the kidneys, leading to a higher risk of lithium toxicity. Instead, sodium intake should remain consistent, and clients should avoid excessive sodium restriction or sudden dietary changes.

C. Eat foods high in potassium. Potassium levels are not significantly affected by lithium therapy. While potassium is essential for overall health, increasing potassium intake is not a specific recommendation for lithium users. Potassium-rich foods are more relevant for clients taking diuretics (e.g., furosemide) or cardiac medications like digoxin.

D. Take the medication 1 hr before meals. Lithium is typically taken with food or milk to minimize gastrointestinal irritation. Taking it on an empty stomach can increase the likelihood of nausea and gastric discomfort, making it harder for clients to adhere to treatment. Clients should follow their provider’s instructions regarding meal timing.

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A nurse is assisting in the care of a female client. Complete the following sentence by using the lists of options. The nurse should first address the client ....... followed by the client's ......

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Naxlex Comprehensive Predictor Exams

A nurse is preparing to insert a miconazole vaginal suppository for a client who has vulvovaginal candidiasis. Which of the following actions is appropriate for inserting this medication?

Correct Answer is B

Explanation

A nurse is reinforcing teaching with a client who has a new prescription for lithium. Which of the following information should the nurse include in the teaching?

Correct Answer is A

Explanation

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A nurse is assisting in the care of a female client.

Complete the following sentence by using the lists of options.

The nurse should first address the client
.......
followed by the client's
.....
.