Nokea
A client receiving Eskalith (lithium carbonate) has a level of 4.5 mEq/L. The nurse should prepare the client for immediate:
- A. Blood transfusion
- B. Hemodialysis
- C. Renal biopsy
- D. Brain scan
Correct Answer: B
Rationale: A lithium level of 4.5 mEq/L indicates severe toxicity, requiring hemodialysis to rapidly remove lithium from the body.
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The nurse is teaching a client with a new diagnosis of chronic obstructive pulmonary disease (COPD) about tiotropium (Spiriva). Which of the following instructions should the nurse include?
- A. Use the inhaler as needed for shortness of breath.
- B. Report any eye pain or vision changes.
- C. Stop the medication if symptoms improve.
- D. Avoid rinsing the mouth after use.
Correct Answer: B
Rationale: Eye pain or vision changes may indicate glaucoma, a serious tiotropium side effect. Options A, C, and D are incorrect.
The nurse is caring for a client who is receiving IV vancomycin for a methicillin-resistant Staphylococcus aureus (MRSA) infection. Which of the following findings would be of GREATest concern to the nurse?
- A. Blood pressure of 130/80 mmHg.
- B. Heart rate of 88 bpm.
- C. Redness at the IV site.
- D. Urine output of 50 mL/hour.
Correct Answer: C
Rationale: Redness at the IV site suggests phlebitis or infiltration, which can lead to tissue damage or reduced vancomycin delivery, requiring immediate action. Options A, B, and D are normal: blood pressure 130/80 mmHg, heart rate 88 bpm, and urine output 50 mL/hour indicate stability.
The client has elected to have epidural anesthesia to relieve labor pain. If the client experiences hypotension, the nurse's first action should be:
- A. Place her in Trendelenburg position.
- B. Slow the IV infusion.
- C. Administer oxygen per nasal cannula.
- D. Speed the IV infusion of normal saline.
Correct Answer: D
Rationale: Hypotension from epidural anesthesia is treated by increasing IV fluid volume with normal saline to restore blood pressure, so D is correct. Trendelenburg is not recommended, slowing the IV would worsen hypotension, and oxygen is secondary.
An adult is admitted with pernicious anemia. Which factor in the client's history is most likely related to the development of pernicious anemia?
- A. The client had an upper gastrointestinal (GI) bleed a year ago.
- B. The client had chemotherapy three months ago.
- C. The client had a gastrectomy six months ago.
- D. The client's mother had iron deficiency anemia
Correct Answer: C
Rationale: Gastrectomy removes the stomach's intrinsic factor-producing cells, leading to vitamin B12 malabsorption, a primary cause of pernicious anemia.
A 3 year-old child is brought to the clinic by his grandmother to be seen for 'scratching his bottom and wetting the bed at night.' Based on these complaints, the nurse would initially assess for which problem?
- A. allergies
- B. scabies
- C. regression
- D. pinworms
Correct Answer: D
Rationale: Pinworms are a common cause of anal itching and can contribute to bed-wetting in children due to discomfort. The nurse should assess for signs of pinworm infection, such as observing the anal area for worms or performing a tape test.