Nokea
A client is a depressed, 48-year-old salesman. A serious concern for the nurse working with depressed clients is the potential of suicide. The time that suicide is most likely to occur is:
- A. In the acutely depressed state
- B. When the depression starts to lift
- C. In the denial phase
- D. During a manic episode
Correct Answer: B
Rationale: When the depression starts to lift, the client is able to make a workable plan, increasing the risk of suicide.
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A client with a history of a heart failure is receiving Furosemide (Lasix). The nurse should monitor the client for:
- A. Hypokalemia
- B. Hyperglycemia
- C. Hypertension
- D. Weight gain
Correct Answer: A
Rationale: Furosemide, a loop diuretic, causes potassium loss, risking hypokalemia, requiring monitoring. Hyperglycemia, hypertension, and weight gain are not primary concerns.
The nurse in the emergency room is caring for a client with multiple rib fractures and a pulmonary contusion. Assessment reveals a respiratory rate of 38, a heart rate of 136, and restlessness. Which associated assessment finding would require immediate intervention?
- A. Occasional small amounts of hemoptysis
- B. Midline trachea with wheezing on auscultation
- C. Subcutaneous air and absent breath sounds
- D. Pain when breathing deeply, with rales in the upper lobes
Correct Answer: C
Rationale: Subcutaneous air and absent breath sounds suggest pneumothorax, requiring immediate intervention (e.g., chest tube). Hemoptysis (A), wheezing (B), and pain/rales (D) are concerning but less urgent.
The client is receiving total parenteral nutrition (TPN). Which assessment finding requires immediate action?
- A. Blood glucose of 200 mg/dL
- B. Weight gain of 1 pound in 24 hours
- C. Temperature of 99.8°F
- D. Dry, cracked lips
Correct Answer: A
Rationale: A blood glucose of 200 mg/dL indicates hyperglycemia, a common TPN complication requiring immediate action to adjust infusion or administer insulin. Weight gain, low-grade fever, and dry lips are less urgent.
Which of the following medications requires close observation for bronchospasm in the client with chronic obstructive pulmonary disease or asthma?
- A. Verapamil (Isoptin)
- B. Amrinone (Inocor)
- C. Epinephrine (Adrenalin)
- D. Propranolol (Inderal)
Correct Answer: D
Rationale: Verapamil has the respiratory side effect of nasal or chest congestion, dyspnea, shortness of breath (SOB), and wheezing. Amrinone has the effect of increased contractility and dilation of the vascular smooth muscle. It has no noted respiratory side effects. Epinephrine has the effect of bronchodilation through stimulation. Propranolol, esmolol, and labetalol are -blocking agents, which can increase airway resistance and cause bronchospasms.
A client is to be discharged from the hospital and is to continue taking warfarin 2.5 mg po bid. Which of the following should be included in her discharge teaching concerning the warfarin therapy?
- A. If you forget to take your morning dose, double the night time dose.'
- B. You should take aspirin instead of acetaminophen (Tylenol) for headaches.'
- C. Carry a medications alert card with you at all times.'
- D. You should use a straight-edge razor when shaving your arms and legs.'
Correct Answer: C
Rationale: Warfarin must always be taken exactly as directed. Clients should be instructed never to skip or double up on their dosage. Aspirin decreases platelet aggregation, which would potentiate the effects of the coumadin. Healthcare providers need to be aware of persons on warfarin therapy prior to the initiation of any diagnostic tests and/or surgery to help prevent bleeding complications. An electric razor should be used to prevent accidental cutting, which can lead to bleeding.