Nokea
The client is in end-stage renal disease and is receiving sodium polystyrene sulfonate (Kayexalate) via an enema. Which data indicate the medication is effective?
- A. The client has 30 mL/hr of urine output.
- B. The serum phosphorus level has decreased.
- C. The client is in normal sinus rhythm.
- D. The client's serum potassium level is 5 mEq/L.
Correct Answer: D
Rationale: Kayexalate lowers serum potassium in hyperkalemia; a level of 5 mEq/L (normal) indicates effectiveness. Urine, phosphorus, or rhythm are unrelated.
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The client recently has had a myocardial infarction. Which medications should the nurse anticipate the health-care provider recommending to prevent another heart attack?
- A. Vitamin K and a nonsteroidal anti-inflammatory drug.
- B. Vitamin E and a daily low-dose aspirin.
- C. Vitamin A and an anticoagulant.
- D. Vitamin B complex and an iron supplement.
Correct Answer: B
Rationale: Low-dose aspirin prevents platelet aggregation, reducing MI risk, per ACC/AHA guidelines. Vitamin E lacks evidence for secondary prevention; other options are irrelevant or contraindicated.
Keflex 250 mg PO q6h is ordered for an adult. The nurse notes that the client's history indicates that she has an allergy to penicillin. What is the most appropriate initial action for the nurse?
- A. Notify the physician
- B. Observe the client carefully after giving the medication
- C. Administer the Keflex IV instead of PO
- D. Ask the client to describe the reaction that she had to penicillin
Correct Answer: D
Rationale: There is often a cross-allergy between penicillin and cephalosporins like Keflex. The nurse should first determine the type of reaction to assess if Keflex is safe.
The client diagnosed with diabetes insipidus is receiving vasopressin intranasally. Which assessment data indicate the medication is effective?
- A. The client reports being able to breathe through the nose.
- B. The client complains of being thirsty all the time.
- C. The client has a blood glucose of 99 mg/dL.
- D. The client is urinating every three (3) to four (4) hours.
Correct Answer: D
Rationale: Vasopressin reduces polyuria in diabetes insipidus; urination every 3–4 hours indicates effectiveness. Nasal breathing, thirst, or glucose are unrelated.
The client diagnosed with multiple sclerosis (MS) is receiving Lioresal (baclofen), a muscle relaxant. Which information should the nurse teach the client/family?
- A. The importance of tapering off medication when discontinuing medication.
- B. Baclofen may cause diarrhea, so the client should take antidiarrheal medication.
- C. The client should not be allowed to drive alone while taking this medication.
- D. The need for follow-up visits to obtain a monthly white blood cell count.
Correct Answer: A
Rationale: Baclofen requires tapering to prevent withdrawal symptoms, like seizures, per FDA warnings. Diarrhea, driving, or WBC counts are not primary concerns.
A woman with a 28 week pregnancy is on the way to the emergency department by ambulance with a tentative diagnosis of abruptio placenta. Which should the nurse do first when the woman arrives?
- A. administer oxygen by mask at 100%
- B. start a second IV with an 18 gauge cannula
- C. check fetal heart rate every 15 minutes
- D. insert urethral catheter with hourly urine outputs
Correct Answer: A
Rationale: administer oxygen by mask at 100%. Administering oxygen in this situation would increase the circulating oxygen in the mother's circulation to the fetus's circulation. This action will minimize complications.