Nokea
A client who had undergone an abdominal hysterectomy is in the recovery room. The surgeon has ordered a 250-mL bolus of normal saline over 1 hour to replace blood loss. The I.V. solution infusing in the client was 1,000 mL normal saline with 40 mEq of potassium chloride at 100 mL/hour. The nurse should: Select all that apply.
- A. Increase the I.V. infusion rate to 250 mL/hour for 1 hour.
- B. Add 250 mL of normal saline to the current infusion bag and continue at 100 mL/hour.
- C. Connect a 250-mL bag of normal saline to the Y-connection and calculate to infuse over 1 hour.
- D. Contact the physician regarding continuation of the primary I.V. infusion during the bolus infusion.
- E. Administer the normal saline bolus via an I.V. infusion pump.
Correct Answer: C,E
Rationale: A separate 250-mL bag via Y-connection and infusion pump ensures accurate delivery of the bolus without altering the primary infusion.
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The nurse is teaching a client with a new diagnosis of gout about dietary management. Which of the following foods should the client include?
- A. Cherries.
- B. Red meat.
- C. Shellfish.
- D. Organ meats.
Correct Answer: A
Rationale: Cherries reduce uric acid levels and inflammation in gout.
A client with a history of deep vein thrombosis is prescribed enoxaparin (Lovenox). Which laboratory value does not require routine monitoring?
- A. Platelet count
- B. Prothrombin time (PT)
- C. Activated partial thromboplastin time (aPTT)
- D. Hemoglobin
Correct Answer: B
Rationale: Enoxaparin, a low-molecular-weight heparin, does not require routine PT monitoring, unlike warfarin, as it primarily affects anti-factor Xa activity.
A client with asthma asks the nurse if she should use her salmeterol (Serevent) inhaler when she exercises and experiences wheezing and shortness of breath. The nurse's best response is which of the following?
- A. Yes, use the inhaler immediately for these symptoms.'
- B. No, this drug is a maintenance drug, not a rescue inhaler.'
- C. Use the inhaler 5 minutes before you exercise to prevent the wheezing.'
- D. This inhaler is for allergic rhinitis, not asthma.'
Correct Answer: B
Rationale: Salmeterol is a long-acting beta-agonist used for asthma maintenance, not for acute symptoms like wheezing during exercise. A rescue inhaler, such as albuterol, is appropriate for acute symptoms.
A 4-year-old child is admitted with dehydration due to gastroenteritis. Which assessment finding indicates severe dehydration?
- A. Dry mucous membranes
- B. Decreased urine output
- C. Sunken fontanelles
- D. Tachycardia
Correct Answer: C
Rationale: Sunken fontanelles in a young child are a sign of severe dehydration, indicating significant fluid loss requiring urgent rehydration.
Your client has a doctor's order for the antihistamine medication diphenhydramine for sleep. What should you do?
- A. Question the order because Benadryl is an antihistamine and not a sleeping medication.
- B. Refuse to give the Benadryl because this medication is a stimulant.
- C. Question the order because Benadryl is contraindicated when the client has a sleep inducement disorder.
- D. Give the Benadryl because sleep inducement is an accepted off label use of this medication.
Correct Answer: D
Rationale: Diphenhydramine (Benadryl) is commonly used off-label for sleep due to its sedative effects, making it an appropriate choice if ordered for this purpose.