Nokea
A client on hemodialysis reports fatigue. The nurse should assess for:
- A. Anemia.
- B. Hyperkalemia.
- C. Dehydration.
- D. Infection.
Correct Answer: A
Rationale: Anemia is common in renal failure due to decreased erythropoietin.
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A short time after cataract surgery, the client complains of nausea. The nurse should first:
- A. Instruct the client to take a few deep breaths until the nausea subsides.
- B. Explain that this is a common feeling that will pass quickly.
- C. Tell the client to call the nurse promptly if vomiting occurs.
- D. Administer an antiemetic, as ordered.
Correct Answer: D
Rationale: Nausea after cataract surgery can indicate increased intraocular pressure or other complications. Administering an antiemetic as ordered is the priority to prevent vomiting, which could increase intraocular pressure and cause complications.
Guaifenesin (Robitussin) 300 mg four times a day has been ordered as an expectorant. The dosage strength of the liquid is 200 mg/5 mL. How many milliliters should the nurse administer for each dose?
Correct Answer: 7.5 mL
Rationale: To calculate the dose: 300 mg ÷ 200 mg/5 mL = 1.5 × 5 mL = 7.5 mL per dose.
A client with renal calculi reports sudden cessation of pain. The nurse should:
- A. Strain all urine.
- B. Administer analgesics.
- C. Check vital signs.
- D. Encourage bed rest.
Correct Answer: A
Rationale: Sudden pain cessation may indicate stone passage; straining urine confirms this.
A client has acute arterial occlusion. The physician has ordered a thrombolytic agent. Before starting the medication, the nurse should:
- A. Review the blood coagulation laboratory values
- B. Test the client's stools for occult blood
- C. Count the client's apical pulse for 1 minute
- D. Check the 24-hour urine output record
Correct Answer: A
Rationale: Before administering a thrombolytic agent for acute arterial occlusion, the nurse must review coagulation lab values (e.g., aPTT, INR, platelets) to assess bleeding risk, as thrombolytics increase hemorrhage potential. Stool testing, pulse counting, and urine output are secondary or unrelated.
The client states she does not understand what causes idiopathic thrombocytopenic purpura (ITP). The nurse provides which of the following explanations?
- A. It is believed that the platelets are coated with antibodies and the spleen sees them as foreign bodies.
- B. It is believed that the liver identifies the platelets as foreign bodies.
- C. It is now believed that the syndrome is related to an underactive immune system.
- D. The cause is unknown.
Correct Answer: A
Rationale: Idiopathic thrombocytopenic purpura (ITP) is an autoimmune condition where antibodies coat platelets, marking them for destruction by the spleen. This leads to a low platelet count. The liver is not primarily involved, ITP is not due to an underactive immune system, and while 'idiopathic' means the exact trigger is unknown, the autoimmune mechanism is well-established.