Nokea
A nurse in a provider's office is reviewing the laboratory results of a client who takes furosemide for hypertension. The nurse notes that the client's potassium level is 3.3 mEq/L. The nurse should monitor the client for which of the following complications?
- A. Hypertension
- B. Hyperkalemia
- C. Cardiac dysrhythmias
- D. Pulmonary edema
Correct Answer: C
Rationale: The correct answer is C: Cardiac dysrhythmias. Furosemide is a loop diuretic that can lead to hypokalemia, which is a potassium deficiency. A potassium level of 3.3 mEq/L is below the normal range (3.5-5.0 mEq/L) and can increase the risk of cardiac dysrhythmias due to the role potassium plays in maintaining the heart's electrical activity. Hypertension (A) is not directly related to low potassium levels. Hyperkalemia (B) is the opposite of what the client is experiencing. Pulmonary edema (D) is not typically associated with low potassium levels.
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A nurse is assessing a client who is 1 day postoperative following a lobectomy and has a chest tube drainage system in place. Which of the following findings by the nurse indicates a need for intervention?
- A. Clear breath sounds on the affected side
- B. Reduction in drainage output
- C. Development of subcutaneous emphysema
- D. Minimal pain at the surgical site
Correct Answer: C
Rationale: Subcutaneous emphysema, where air gets trapped under the skin, may indicate an underlying pneumothorax and should be reported to the provider.
A nurse is caring for a client who has pericarditis and reports feeling a new onset of palpitations and shortness of breath. Which of the following assessments should indicate to the nurse that the client may have developed atrial fibrillation?
- A. Different apical and radial pulses.
- B. Shortness of breath on exertion.
- C. Excessive sweating.
- D. Systolic blood pressure of 150 mm Hg.
Correct Answer: A
Rationale: The correct answer is A: Different apical and radial pulses. In atrial fibrillation, the atria quiver instead of contracting effectively, leading to irregular heartbeat and pulse. This results in a discrepancy between the apical (heard by auscultation) and radial (felt at the wrist) pulses. Shortness of breath on exertion (B), excessive sweating (C), and systolic blood pressure of 150 mm Hg (D) are not specific to atrial fibrillation and can occur in various conditions.
A nurse is assessing a client before a packed RBC transfusion. What data is most important to obtain?
- A. Blood pressure
- B. Temperature
- C. Respiratory rate
- D. Oxygen saturation
Correct Answer: B
Rationale: The correct answer is B: Temperature. Before a packed RBC transfusion, it is crucial to assess the client's temperature as hyperthermia can indicate a possible transfusion reaction. Monitoring temperature helps in early detection and intervention. Blood pressure (A) is important but not the most crucial in this context. Respiratory rate (C) and oxygen saturation (D) are relevant but may not indicate an immediate issue with the transfusion. Other choices are not provided.
A nurse is instructing a client how to decrease the nausea associated with chemotherapy and radiation. Which of the following statements indicates an understanding of the teaching?
- A. I will eat food that are served at room temperature.
- B. I will avoid drinking liquids with meals.
- C. I will eat spicy foods to improve appetite.
- D. I will drink hot liquids to settle my stomach.
Correct Answer: A
Rationale: The correct answer is A: "I will eat food that are served at room temperature." This is correct because consuming foods at room temperature helps reduce nausea associated with chemotherapy and radiation. Cold foods can worsen nausea, while hot foods can trigger vomiting. Avoiding extreme temperatures can help alleviate nausea.
Choice B is incorrect because avoiding liquids with meals can lead to dehydration and worsen nausea. Choice C is incorrect because spicy foods can exacerbate nausea rather than improve appetite. Choice D is incorrect because drinking hot liquids can aggravate nausea.
A nurse is admitting a client who has acute pancreatitis. Which of the following provider prescriptions should the nurse anticipate?
- A. Pantoprazole 80 mg IV bolus twice daily
- B. Furosemide 40 mg IV
- C. Lactulose 20 mg PO
- D. Acetaminophen 650 mg PO
Correct Answer: A
Rationale: The correct answer is A: Pantoprazole 80 mg IV bolus twice daily. In acute pancreatitis, gastric acid hypersecretion can occur, leading to exacerbation of pancreatic inflammation. Pantoprazole is a proton pump inhibitor that helps reduce gastric acid secretion, which can alleviate pancreatic irritation. IV administration ensures rapid onset of action.
B: Furosemide is a diuretic used for conditions like heart failure or edema, not indicated for acute pancreatitis.
C: Lactulose is a laxative used for hepatic encephalopathy to reduce ammonia levels, not indicated for acute pancreatitis.
D: Acetaminophen is a pain reliever, but it does not address the underlying cause of acute pancreatitis.