Nokea
A 70-year-old client is almost finished receiving her second unit of packed red blood cells. The client, who weighs 80 lb, has started complaining of being short of breath and now has crackles in the bases of her lungs. After slowing or stopping the transfusion, the most appropriate initial nursing action would be to:
- A. Raise the client's head and place her feet in a dependent position
- B. Notify the physician
- C. Place the client on 2 liters of O2 via nasal cannula
- D. Administer furosemide (Lasix) 20 mg IV push
Correct Answer: A
Rationale: Raising the head and placing feet in a dependent position reduces venous return and pulmonary congestion, addressing transfusion-related circulatory overload.
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A client's congestive heart failure has been treated, and he will soon be discharged. Discharge teaching should include instruction to call the physician if he notices a 2-lb weight gain in a 24-hour period. Increased weight gain may indicate:
- A. A diet too high in calories and saturated fat
- B. Decreasing cardiac output
- C. Decreasing renal function
- D. Development of diabetes insipidus
Correct Answer: B
Rationale: A 2-lb weight gain in 24 hours suggests fluid retention due to decreasing cardiac output, activating the renin-angiotensin-aldosterone system.
The child with seizure disorder is being treated with phenytoin (Dilantin). Which of the following statements by the patient's mother indicates to the nurse that the patient is experiencing a side effect of Dilantin therapy?
- A. She is very irritable lately.'
- B. She sleeps quite a bit of the time.'
- C. Her gums look too big for her teeth.'
- D. She has gained about 10 pounds in the last six months.'
Correct Answer: C
Rationale: Gingival hyperplasia (overgrown gums) is a common side effect of phenytoin (Dilantin). Irritability, excessive sleep, and weight gain are not typical side effects of this medication.
A client with a history of stroke is admitted with complaints of hemiparesis. The nurse should give priority to:
- A. Providing physical therapy
- B. Administering pain medication
- C. Monitoring blood pressure
- D. Administering anticoagulants
Correct Answer: A
Rationale: Physical therapy improves strength and mobility in hemiparesis post-stroke, promoting recovery.
The priority nursing goal when working with an autistic child is:
- A. To establish trust with the child
- B. To maintain communication with the family
- C. To promote involvement in school activities
- D. To maintain nutritional requirements
Correct Answer: A
Rationale: The priority nursing goal when working with an autistic child is establishing a trusting relationship. Maintaining a relationship with the family is important but having the trust of the child is a priority. To promote involvement in school activities is inappropriate for a child who is autistic. Maintaining nutritional requirements is not the primary problem of the autistic child.
An elderly patient has been taking 80 mg of furosemide (Lasix) bid. The nurse notes that the patient's most recent potassium level is 2.5mEq/L. The nurse should:
- A. Continue the medication as ordered
- B. Administer the morning dose only
- C. Give the medication with orange juice
- D. Withhold the medication and notify the physician
Correct Answer: D
Rationale: A potassium level of 2.5 mEq/L indicates hypokalemia, a serious side effect of furosemide, a potassium-wasting diuretic. The nurse should withhold the medication and notify the physician to address the electrolyte imbalance.