Nokea
A client diagnosed with cirrhosis of the liver and ascites is receiving spironolactone (Aldactone). The nurse understands that this medication spares elimination of which element?
- A. Sodium
- B. Potassium
- C. Phosphate
- D. Albumin
Correct Answer: B
Rationale: Potassium. If ascites is present in the client with cirrhosis of the liver, potassium-sparing diuretics such as Aldactone should be administered because it inhibits the action of aldosterone on the kidneys.
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The nurse is preparing to care for the client with Ebola, a febrile, hemorrhagic disease. After selecting a disposable surgical hood that extends to the shoulders, what additional PPE should the nurse obtain? Select all that apply.
- A. Docimeter
- B. Disposable N95 respirator
- C. Disposable full face shield
- D. Cloth gown that cannot be reused
- E. Two pair nitrile examination gloves
- F. Boot covers extending to mid-calf
Correct Answer: B,C,E,F
Rationale: B: N95 respirator protects against possible airborne transmission. C: Face shield prevents mucosal exposure. E: Double gloves enhance protection. F: Boot covers prevent lower leg exposure. A: Docimeters are for radiation. D: Cloth gowns are inadequate; impermeable gowns are needed.
The nurse is to administer cefazolin sodium 1 g in 100 mL 0.9% NaCl over 30 minutes. At what rate in mL/hour should the nurse plan to set the infusion pump?
Correct Answer: 200
Rationale: 100 mL/ 0.5 hours = 200 mL/hour.
The client is placed on contact precautions. When should the nurse caring for the client plan to put on disposable examination gloves?
- A. As soon as the nurse enters the client's room
- B. Only if anticipating contact with the client's wound
- C. Only if anticipating contact with blood or body fluids
- D. Only if providing care within 3 feet of the client
Correct Answer: A
Rationale: A: Contact precautions require gloves upon entering the room to prevent transmission of infectious organisms, regardless of anticipated contact.
After a client has an enteral feeding tube inserted, the most accurate method for verification of placement is
- A. abdominal x-ray
- B. auscultation
- C. flushing tube with saline
- D. aspiration for gastric contents
Correct Answer: A
Rationale: abdominal x-ray. Placement should be verified by radiograph to determine that the tube is in the stomach or intestine rather than in the airways.
A client with amyotrophic lateral sclerosis has a percutaneous endoscopic gastrostomy (PEG) tube for the administration of feedings and medications. Which nursing action is appropriate?
- A. Pulverize all medications to a powdery condition
- B. Squeeze the tube before using it to break up stagnant liquids
- C. Cleanse the skin around the tube daily with hydrogen peroxide
- D. Flush adequately with water before and after using the tube
Correct Answer: D
Rationale: Flush adequately with water before and after using the tube. Flushing the tube before and after use not only provides for good tube maintenance, it is flushing that moves medications through. Not all medications should be crushed, for example sustained release preparations should not be cut or pulverized. Stagnant liquids are reduced by flushing after tube use. Cleansing is important, but soap and water are sufficient without the added irritation of hydrogen peroxide.