Nokea
A client has been admitted with acute renal failure. What should the nurse do? Select all that apply.
- A. Elevate the head of the bed 30 to 45 degrees.
- B. Take vital signs.
- C. Establish an I.V. access site.
- D. Call the admitting physician for orders.
- E. Contact the hemodialysis unit.
Correct Answer: B,C,D
Rationale: Taking vital signs, establishing IV access, and contacting the physician are immediate actions to assess and stabilize the client with acute renal failure.
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The nurse is developing a program on skin cancer prevention for a community group. Which of the following should be included in the program? Select all that apply.
- A. Purchase sunscreen containing benzophenoness to check UVA and UVB rays.
- B. Use sunscreen with a minimum of 15 sun protection factor (SPF).
- C. Obtain genetic screening to identify risk of melanoma.
- D. Apply sunscreen only on sunny days, especially between 10 AM and 2 PM.
- E. Have a pigmented lesion biopsied by shaving if it looks suspicious.
- F. Rub baby oil to lubricate skin before going out in the sun.
Correct Answer: A,B
Rationale: Sunscreen with benzophenones and SPF 15 or higher protects against UVA/UVB rays. Genetic screening is not routine, sunscreen should be used daily, shave biopsies are inappropriate, and baby oil increases UV damage.
A client with acute renal failure has metabolic acidosis. The nurse expects:
- A. Sodium bicarbonate administration.
- B. Increased potassium intake.
- C. Fluid bolus.
- D. High-protein diet.
Correct Answer: A
Rationale: Sodium bicarbonate corrects metabolic acidosis in acute renal failure.
The nurse is caring for a child who is immunocompromised and diagnosed with varicella. The nurse should request a prescription from the physician for which medication?
- A. amoxicillin-clavulanate
- B. acyclovir
- C. doxycycline
- D. azithromycin
Correct Answer: B
Rationale: Acyclovir is an antiviral medication used to treat varicella (chickenpox) in immunocompromised patients to reduce severity and complications. Choice A (amoxicillin-clavulanate) and Choice D (azithromycin) are antibiotics, ineffective against viral infections. Choice C (doxycycline) is an antibiotic and not suitable for children under 8 due to the risk of tooth discoloration.
The physician prescribes metoclopramide hydrochloride (Reglan) for the client with hiatal hernia. The nurse plans to instruct the client that this drug is used in hiatal hernia therapy to accomplish which of the following objectives?
- A. Increase tone of the esophageal sphincter.
- B. Neutralize gastric secretions.
- C. Ease gastric emptying.
- D. Reduce secretion of digestive juices.
Correct Answer: C
Rationale: Metoclopramide promotes gastric emptying, reducing the volume of gastric contents that can reflux in hiatal hernia.
The nurse is to administer flumazenil (Mazicon) I.V. for reversal of sedation. Which of the following interventions should be included in the care plan? Select all that apply.
- A. Administer the medication as a 2-mg bolus.
- B. Give the medication undiluted in incremental doses.
- C. Be alert for shivering and hypotension.
- D. Use only a free-flowing I.V. line in a large vein.
- E. Monitor the client's level of consciousness.
Correct Answer: B,C,D,E
Rationale: Flumazenil is given undiluted in incremental doses (B), via a free-flowing IV line (D), with monitoring for side effects like shivering and hypotension (C) and level of consciousness (E). A 2-mg bolus (A) is incorrect, as flumazenil is titrated in smaller doses.