Nokea
A client has been taking furosemide (Lasix) for the past week. The nurse recognizes which finding may indicate the client is experiencing a negative side effect from the medication?
- A. Weight gain of 5 pounds
- B. Edema of the ankles
- C. Gastric irritability
- D. Decreased appetite
Correct Answer: D
Rationale: Decreased appetite. Lasix causes a loss of potassium if a supplement is not taken. Signs and symptoms of hypokalemia include anorexia, fatigue, nausea, decreased GI motility, muscle weakness, and dysrhythmias.
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A newly admitted elderly client is severely dehydrated. When planning care for this client, which task is appropriate to assign to an unlicensed assistive personnel (UAP)?
- A. Converse with the client to determine if the mucous membranes are impaired
- B. Report output of less than 30 ml/hr
- C. Provide oral fluids every hour
- D. Check skin turgor every 4 hours
Correct Answer: C
Rationale: Providing oral fluids is a routine task with predictable outcomes, suitable for a UAP, while the other tasks require clinical judgment or assessment skills.
A 69-year-old woman has been receiving total parenteral nutrition (TPN) for several weeks. If the TPN were abruptly discontinued, the nurse would expect the patient to exhibit
- A. tinnitus, vertigo, blurred vision.
- B. fever, malaise, anorexia.
- C. diaphoresis, confusion, tachycardia.
- D. hyperpnea, flushed face, diarrhea.
Correct Answer: C
Rationale: insulin levels remain high while glucose levels decline; results in hypoglycemia; will also see restlessness, headache, weakness, irritability, apprehension, lack of muscle coordination
An adolescent for a lumbar puncture.
It is MOST important that the nurse make which of the following statements?
- A. Don't worry because a general anesthetic will be used.'
- B. You can't drink fluids for eight hours before the Test .'
- C. You will remain flat in bed for eight hours after the Test .'
- D. A compression bandage will be in place for ten hours after the Test .'
Correct Answer: C
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) general anesthetic is not used (2) fluids are not restricted before the Test (3) correct-to prevent a post-lumbar puncture headache, client should remain flat in bed for eight hours after the Test (4) inappropriate for this procedure
A client receives morphine sulfate after being admitted to the emergency room in acute respiratory distress. He is very anxious, edematous, and cyanotic. Which of the following should the nurse recognize as the desired response to the medication?
- A. Increase in pulse pressure.
- B. Decrease in anxiety.
- C. Depression of the sympathetic nervous system.
- D. Enhanced ventilation and decreased cyanosis.
Correct Answer: B
Rationale: morphine sulfate is administered to minimize anxiety associated with respiratory distress from pulmonary edema
The nurse is caring for a woman who is admitted following a beating by her husband. The woman says, 'It wasn't really his fault. Dinner was late.' The husband arrives to visit his wife with a large bouquet of flowers and a box of chocolates. The woman later says to the nurse, 'He feels so bad about what he did and says it will never happen again.' What concept should guide the nurse when replying to the client?
- A. Men who abuse their wives and then repent usually do not do it again.
- B. The woman is quite perceptive and should be safe when she is discharged.
- C. Abuse is often followed by repentance and then again by abuse.
- D. Spousal abuse is usually a result of misbehavior on the part of the abused.
Correct Answer: C
Rationale: The cycle of abuse often includes remorse followed by repeated abuse, guiding the nurse to educate about patterns, not assume safety or blame the victim.