Nokea
A client is admitted to the hospital with diabetic ketoacidosis. The emergency room nurse should anticipate the administration of:
- A. Humulin N
- B. Humulin R
- C. Humulin U
- D. Humulin L
Correct Answer: B
Rationale: Regular insulin is rapid acting and indicated in an emergency situation.
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The nurse is caring for a client with a history of preterm labor. Which medication is most likely to be ordered to halt preterm contractions?
- A. Magnesium sulfate
- B. Nifedipine
- C. Ritodrine
- D. Indomethacin
Correct Answer: B
Rationale: Nifedipine a calcium channel blocker is commonly used as a tocolytic to halt preterm contractions by relaxing uterine smooth muscle. Ritodrine is less used due to side effects magnesium sulfate is more for preeclampsia and indomethacin is used in specific cases.
A client is admitted with sickle cell crises and sequestration. Upon assessing the client, the nurse would expect to find:
- A. Decreased blood pressure
- B. Moist mucus membranes
- C. Decreased respirations
- D. Increased blood pressure
Correct Answer: A
Rationale: Sickle cell crisis with sequestration can lead to hypovolemia due to blood pooling in organs, resulting in decreased blood pressure.
The nurse is caring for a client with a diagnosis of chorioamnionitis. Which diagnostic test is most likely to be ordered?
- A. Complete blood count
- B. Amniotic fluid analysis
- C. Both A and B
- D. Neither A nor B
Correct Answer: C
Rationale: Chorioamnionitis requires a complete blood count to assess for infection (e.g. elevated white blood cells) and amniotic fluid analysis to confirm infection. Both tests are commonly ordered.
A client with a history of chronic lymphocytic leukemia is admitted with complaints of lymphadenopathy. The nurse should give priority to:
- A. Monitoring for infection
- B. Administering pain medication
- C. Monitoring blood pressure
- D. Administering chemotherapy
Correct Answer: A
Rationale: Lymphadenopathy in chronic lymphocytic leukemia increases infection risk, so monitoring for infection is the priority.
A male client is scheduled to have angiography of his left leg. The nurse needs to include which of the following when preparing the client for this procedure?
- A. Validate that he is not allergic to iodine or shellfish.
- B. Instruct him to start active range of motion of his left leg immediately following the procedure.
- C. Inform him that he will not be able to eat or drink anything for 4 hours after the procedure.
- D. Inform him that vital signs will be taken every hour for 4 hours after the procedure.
Correct Answer: A
Rationale: Angiography, an invasive radiographic examination, involves the injection of a contrast solution (iodine) through a catheter that has been inserted into an artery. The client is kept on complete bed rest for 6-12 hours after the procedure. The extremity in which the catheter was inserted must be immobilized and kept straight during this time. The contrast dye, iodine, is nephrotoxic. The client must be instructed to drink a large quantity of fluids to assist the kidneys in excreting this contrast media. The major complication of this procedure is hemorrhage. Vital signs are assessed every 15 minutes initially for signs of bleeding.