Nokea
A 5 year-old has been rushed to the emergency room several hours after acetaminophen poisoning. Which laboratory result should receive attention by the nurse?
- A. Sedimentation rate
- B. Profile 2
- C. Bilirubin
- D. Neutrophils
Correct Answer: C
Rationale: Bilirubin. Bilirubin, along with liver enzymes ALT and AST, may rise in the second stage (1-3 days) after a significant overdose, indicating cellular necrosis and liver dysfunction.
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In providing care for a client with pain from a sickle cell crisis, which one of the following medication orders for pain control should be questioned by the nurse?
- A. Demerol
- B. Morphine
- C. Methadone
- D. Codeine
Correct Answer: A
Rationale: Demerol. Meperidine is not recommended in clients with sickle cell disease. Normeperidine, a metabolite of meperidine, is a central nervous system stimulant that produces anxiety, tremors, myoclonus, and generalized seizures when it accumulates with repetitive dosing. Clients with sickle cell disease are particularly at risk for normeperidine-induced seizures.
The nurse is evaluating the client's home medications and notes the client with angina is taking an antidepressant. Which intervention should the nurse implement because the client is taking this medication?
- A. Ask the client if there is a plan for suicide.
- B. Assess the client's depression on a 1-to-10 scale.
- C. Explain this medication cannot be taken because of the angina.
- D. Request a referral to the hospital psychologist.
Correct Answer: A
Rationale: Antidepressants in angina patients raise suicide risk concerns; assessing for a plan is the priority to ensure safety.
The health care provider orders an IV aminophylline infusion at 30 mg/hr. The pharmacy sends a 1,000 ml bag of D5W containing 500 mg of aminophylline. In order to administer 30 mg per hour, the RN will set the infusion rate at:
- A. 20 ml per hour
- B. 30 ml per hour
- C. 50 ml per hour
- D. 60 ml per hour
Correct Answer: D
Rationale: 60 ml per hour. Using the ratio method to calculate infusion rate: mg to be given (30) : ml to be infused (X) :: mg available (500) : ml of solution (1,000). Solve for X by cross-multiplying: 30 × 1,000 = 500 × X, 30,000 = 500X, X = 30,000 / 500, X = 60 ml per hour.
A 4 year-old child is admitted with burns on his legs and lower abdomen. When assessing the child's hydration status, which of the following indicates a less than adequate fluid replacement?
- A. Decreasing hematocrit and increasing urine volume
- B. Rising hematocrit and decreasing urine volume
- C. Falling hematocrit and decreasing urine volume
- D. Stable hematocrit and increasing urine volume
Correct Answer: B
Rationale: Rising hematocrit and decreasing urine volume. A rising hematocrit indicates a decreased total blood volume, a finding consistent with dehydration.
The client in end-stage renal disease is receiving aluminium hydroxide (Amphojel). Which assessment data indicate the medication is effective?
- A. The client denies complaints of indigestion.
- B. The client is not experiencing burning on urination.
- C. The client has had a normal, soft bowel movement.
- D. The client's phosphate level has decreased.
Correct Answer: D
Rationale: Amphojel binds phosphate in ESRD, lowering serum levels; decreased phosphate indicates effectiveness. Indigestion, urination, or bowel movements are unrelated.