Nokea
A 63-year-old woman is taking digitalis, baby aspirin, potassium (K-Dur), and furosemide (Lasix) daily. She complains of multiple symptoms, which include muscle cramps and facial tics. Physical exam reveals positive Chvostek's and Trousseau's signs, hypotension, and confusion. The nurse suspects she has hypomagnesemia. What else should the nurse expect?
- A. Laboratory tests to reveal high serum calcium and potassium levels
- B. Laboratory tests to reveal low serum calcium and potassium levels
- C. Altered acid-base balance, which requires administration of NaHCO3 intravenously in addition to treatment for hypomagnesemia
- D. An order for an ECG to monitor brain function
Correct Answer: B
Rationale: Hypomagnesemia often accompanies low calcium and potassium, as seen with furosemide use, explaining symptoms like cramps and tetany.
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The nurse is to start oxygen therapy via nasal cannula. Which action is correct?
- A. Set the oxygen at 12 L/min.
- B. Lubricate the cannula with petrolatum before inserting.
- C. Give 100% oxygen by mask before inserting.
- D. Insert the cannula 1 cm into the nostrils.
Correct Answer: D
Rationale: Inserting the cannula 1 cm into the nostrils ensures proper oxygen delivery. High flow rates, petrolatum, or mask pre-oxygenation are incorrect.
The nurse is inserting an indwelling urinary catheter in an adult woman. The nurse locates landmarks before inserting the catheter. The urethral opening is located:
- A. above the clitoris.
- B. behind the vagina.
- C. between the clitoris and the vagina.
- D. between the vagina and the rectum.
Correct Answer: C
Rationale: The female urethral opening is located between the clitoris and vagina, a key landmark for catheter insertion to avoid incorrect placement.
A client is receiving an intravenous (IV) infusion for pain control. When caring for this client, which one of these actions can the RN safely assign to an unlicensed assistive personnel (UAP)?
- A. Ask the client the degree of relief and document the client's response
- B. Decrease the set rate on the pump by 2 ml/minute
- C. Check the IV site for drainage and loose tape
- D. Assist the client with ambulation and a gown change with supervision
Correct Answer: D
Rationale: When directing the UAP, communicate clearly and specifically what the task is and what should be reported to the nurse. Implementation of routine tasks should be delegated since they do not require independent judgment.
The client with multiple myeloma is admitted and prescribed cyclophosphamide (Cytoxan). During the treatment, the nurse should instruct the client to:
- A. Increase the fiber in his diet.
- B. Report hematuria.
- C. Avoid antacid consumption.
- D. Increase his activity.
Correct Answer: B
Rationale: Cyclophosphamide can cause hemorrhagic cystitis, so reporting hematuria is critical. Fiber, antacids, and activity are not directly related to this medication's side effects.
The nurse is caring for a client who is postoperative day 1 after a nephrectomy. Which of the following findings should the nurse report immediately?
- A. Pain at the incision site.
- B. Temperature of 100.8°F (38.2°C).
- C. Urine output of 30 mL/hour.
- D. Blood pressure of 130/80 mmHg.
Correct Answer: B
Rationale: A temperature of 100.8°F suggests infection, a serious post-nephrectomy complication. Options A, C, and D are normal or expected.