Nokea
A client is being monitored using a central venous pressure monitor. If the pressure is 2 cm of water, the nurse should:
- A. Call the doctor immediately
- B. Slow the intravenous infusion
- C. Listen to the lungs for rales
- D. Administer a diuretic
Correct Answer: B
Rationale: A CVP of 2 cm of water is low, suggesting hypovolemia; slowing the IV infusion prevents fluid overload while addressing the issue.
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The nurse has just admitted a client with emphysema. Arterial blood gas results indicate hypoxia. Which physician prescription would the nurse implement for the best improvement in the client's hypoxia?
- A. Elevate the head of the bed 45°
- B. Encourage diaphragmatic breathing
- C. Initiate an Alupent nebulizer treatment
- D. Start Oâ‚‚ at 2 L/min
Correct Answer: D
Rationale: Low-flow oxygen (2 L/min) directly addresses hypoxia in emphysema by improving arterial oxygen levels, making it the most effective intervention.
A client on the postpartum unit has a proctoepisiotomy. The nurse should anticipate administering which medication?
- A. Dulcolax suppository
- B. Docusate sodium (Colace)
- C. Methyergonovine maleate (Methergine)
- D. Bromocriptine sulfate (Parlodel)
Correct Answer: B
Rationale: Docusate sodium (Colace) is a stool softener, appropriate to prevent straining and promote healing after a proctoepisiotomy.
A client is admitted to the unit 2 hours after an injury with second-degree burns to the face, trunk, and head. The nurse would be most concerned with the client developing what?
- A. Hypovolemia
- B. Laryngeal edema
- C. Hypernatremia
- D. Hyperkalemia
Correct Answer: B
Rationale: Laryngeal edema is a critical concern with facial and head burns due to the risk of airway obstruction.
The nurse caring for a client diagnosed with metastatic cancer of the bone is exhibiting mental confusion and a BP of 150/100. Which laboratory value would correlate with the client's symptoms reflecting a common complication with this diagnosis?
- A. Potassium 5.2 mEq/L
- B. Calcium 13 mg/dL
- C. Inorganic phosphorus 1.7 mEq/L
- D. Sodium 138 mEq/L
Correct Answer: B
Rationale: Bone metastasis often causes hypercalcemia (calcium 13 mg/dL is elevated), leading to confusion and hypertension. The other values are normal or unrelated.
A client who has glaucoma is to have miotic eyedrops instilled in both eyes. The nurse knows that the purpose of the medication is to:
- A. Anesthetize the cornea
- B. Dilate the pupils
- C. Constrict the pupils
- D. Paralyze the muscles of accommodation
Correct Answer: C
Rationale: Miotics constrict the pupils, increasing aqueous humor outflow to reduce intraocular pressure in glaucoma.