Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A. Potassium 5.5 mEq/L
A high potassium level can increase the risk of digoxin toxicity. The normal range for potassium is typically 3.5 to 5.0 mEq/L, so a level of 5.5 mEq/L should be reported.
B. Potassium 3.8 mEq/L
A potassium level of 3.8 mEq/L is within the normal range and would not typically increase the risk of digoxin toxicity.
C. Potassium 4.5 mEq/L
A potassium level of 4.5 mEq/L is within the normal range and would not typically increase the risk of digoxin toxicity.
D. Potassium 2.9 mEq/L
A low potassium level can also increase the risk of digoxin toxicity, but the question asks for the result that does not increase the risk, making 2.9 mEq/L incorrect in this context.
This question is an excerpt from Nurse Dive's nursing test bank - Ati Advanced Concept Proctored Exam 240. Take the full exam now
Full Explanation
Choice A reason: A high potassium level can increase the risk of digoxin toxicity. The normal range for potassium is typically 3.5 to 5.0 mEq/L, so a level of 5.5 mEq/L should be reported.
Choice B reason: A potassium level of 3.8 mEq/L is within the normal range and would not typically increase the risk of digoxin toxicity.
Choice C reason: A potassium level of 4.5 mEq/L is within the normal range and would not typically increase the risk of digoxin toxicity.
Choice D reason: A low potassium level can also increase the risk of digoxin toxicity, but the question asks for the result that does not increase the risk, making 2.9 mEq/L incorrect in this context.
Similar Questions
A nurse is caring for a client who has depression. After two days of treatment, the nurse notices that the client is suddenly more active and there are no longer signs of a depressive state. Which of the following interventions should the nurse recommend for the plan of care?
A. Encourage family to take the client out of the facility for short periods of time.
While it may be beneficial for the client's mood, taking the client out of the facility does not directly address the sudden change in behavior.
B. Reward the client for her change in behavior.
Rewarding the client for a change in behavior does not address the potential risks associated with a sudden change in mental status.
C. Ask the client why her behavior has changed.
Asking the client why their behavior has changed could be part of an assessment, but it is not an immediate safety intervention.
D. Monitor the client's whereabouts at all times.
Monitoring the client's whereabouts at all times is important as a sudden lift in depressive symptoms can sometimes precede a suicide attempt, and close observation is necessary.
Full Explanation
Choice A reason: While it may be beneficial for the client's mood, taking the client out of the facility does not directly address the sudden change in behavior.
Choice B reason: Rewarding the client for a change in behavior does not address the potential risks associated with a sudden change in mental status.
Choice C reason: Asking the client why their behavior has changed could be part of an assessment, but it is not an immediate safety intervention.
Choice D reason: Monitoring the client's whereabouts at all times is important as a sudden lift in depressive symptoms can sometimes precede a suicide attempt, and close observation is necessary.
A nurse is caring for a client three days after admission to an acute care mental health facility for treatment of major depression. The client leaves her current activity, approaches the nurse, and states, "There's no reason to go on living. I just want to end it all." Which of the following nursing interventions is appropriate?
A. Ask the client if she has a plan to commit suicide.
Directly asking the client about suicidal plans is a critical step in assessing risk and determining the need for immediate intervention.
B. Notify the client's family and request a visitor to stay with the client until thoughts of suicide are gone.
While involving the family is important, it does not address the immediate risk the client may pose to herself.
C. Recognize the attempt at manipulation and escort the client back to her activity.
Recognizing the statement as a manipulation attempt is inappropriate; all expressions of suicidal ideation should be taken seriously.
D. Assist the client to her room and allow her to rest before resuming activity.
Allowing the client to rest does not address the immediate risk of suicide and the need for urgent assessment and intervention.
Full Explanation
Choice A reason: Directly asking the client about suicidal plans is a critical step in assessing risk and determining the need for immediate intervention.
Choice B reason: While involving the family is important, it does not address the immediate risk the client may pose to herself.
Choice C reason: Recognizing the statement as a manipulation attempt is inappropriate; all expressions of suicidal ideation should be taken seriously.
Choice D reason: Allowing the client to rest does not address the immediate risk of suicide and the need for urgent assessment and intervention.
A newly admitted patient in an acute manic state has a nursing diagnosis of at risk for injury related to hyperactivity. Which nursing intervention is most appropriate?
A. Have the patient sit in his room while you review all the rules of the unit.
Having the patient sit alone while reviewing rules does not address the immediate risk of injury due to hyperactivity.
B. Reinforce previously learned coping mechanisms to calm the patient down.
Reinforcing coping mechanisms can help the patient manage hyperactivity and reduce the risk of injury.
C. Place the patient in a room with another hyperactive patient.
Placing the patient with another hyperactive patient could potentially exacerbate the situation and increase the risk of injury.
D. Administer antipsychotic medication as ordered and as needed by the physician.
While administering medication may be necessary, it should be done in conjunction with other interventions that address behavior management.
Full Explanation
Choice A reason: Having the patient sit alone while reviewing rules does not address the immediate risk of injury due to hyperactivity.
Choice B reason: Reinforcing coping mechanisms can help the patient manage hyperactivity and reduce the risk of injury.
Choice C reason: Placing the patient with another hyperactive patient could potentially exacerbate the situation and increase the risk of injury.
Choice D reason: While administering medication may be necessary, it should be done in conjunction with other interventions that address behavior management.