Nokea
A client is receiving a continuous I.V. infusion of heparin. The nurse should monitor the client for which of the following adverse effects?
- A. Hypotension.
- B. Bleeding.
- C. Hypoglycemia.
- D. Tachycardia.
Correct Answer: B
Rationale: Heparin is an anticoagulant, and its primary adverse effect is bleeding, which the nurse should monitor closely.
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Select the complication of a blood transfusion that is accurately paired with its preventive measure.
- A. Hemolysis: Typing and cross matching the blood and checking for ABO compatibility prior to administration
- B. Hemolysis: Insuring that the client does not have a prior history of hemolysis in the past
- C. Febrile reactions: Insuring that the client does not have a prior history of hemolysis in the past
- D. Febrile reactions: Typing and cross matching the blood and checking for ABO compatibility prior to administration
Correct Answer: A
Rationale: Hemolysis is prevented by ensuring ABO compatibility and proper typing and cross-matching to avoid immune reactions.
Which of the following skin care instructions would be appropriate for a client receiving radiation therapy?
- A. Avoid shaving with straight-edge razors.
- B. Clean the skin daily with antibacterial soap.
- C. Apply moisturizing lotion before and after each treatment.
- D. Keep the radiated area covered with a sterile gauze dressing.
Correct Answer: A
Rationale: Avoiding straight-edge razors prevents skin irritation in the radiated area, which is sensitive.
Ergonovine maleate (Ergotrate) 200 mcg I.M. has been ordered. The ampule label reads 0.2 mg/mL. The nurse should administer how many milliliters?
- A. 1 mL
- B. 2 mL
- C. 0.5 mL
- D. 1.5 mL
Correct Answer: C
Rationale: First, convert micrograms to milligrams: 200 mcg = 0.2 mg. Then: 0.2 mg / X mL = 0.2 mg / 1 mL, so X = 1 mL.
The nurse is caring for a client taking memantine. Which data should the nurse monitor for this client?
- A. Liver function studies
- B. Complete blood count
- C. Renal function studies
- D. Pulmonary function studies
Correct Answer: C
Rationale: Memantine is a medication used to treat moderate to severe Alzheimer's disease. This medication needs to be avoided in clients with severe renal dysfunction, and a reduced dosage is needed in moderate renal dysfunction. The other options are not specifically associated with this medication.
Which of the following theories of pain are you utilizing when you recognize the fact that some of the factors that open this 'gate' to pain are low endorphins and anxiety and that some of the factors that close this 'gate' to pain are decreased anxiety and fear?
- A. Moritz Schiff's theory of pain
- B. The Intensive Theory of Pain
- C. Melzack and Wall's theory of pain
- D. The Specificity Theory of Pain
Correct Answer: C
Rationale: Melzack and Wall's Gate Control Theory posits that pain perception is modulated by factors like anxiety (opening the gate) and reduced anxiety or endorphins (closing the gate).