Nokea
A client with a burn injury is prescribed silver sulfadiazine. What should the nurse monitor for?
- A. Hypokalemia.
- B. Leukopenia.
- C. Hyperglycemia.
- D. Hypertension.
Correct Answer: B
Rationale: Silver sulfadiazine can cause leukopenia, so monitoring white blood cell counts is essential.
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Your pregnant client has a new order for a medication. What principle should you apply to this new medication?
- A. The fact that drugs classified as categories C, D and X are contraindicated for women who are pregnant.
- B. The fact that drugs classified as categories A, B and C are contraindicated for women who are pregnant.
- C. The fact that drugs classified as categories C, D and E are contraindicated for women who are pregnant.
- D. The fact that drugs classified as categories C, D and Z are contraindicated for women who are pregnant.
Correct Answer: A
Rationale: Drugs in FDA pregnancy categories C, D, and X carry risks (potential harm, known harm, or absolute contraindication, respectively) and are generally contraindicated in pregnancy unless benefits outweigh risks.
In the early postoperative period, the nurse notes a bright red, 3' x 5' area of drainage on the client's abdominal laparotomy dressing. What should be the nurse's first action in response to this observation?
- A. Ignore it because drainage is normal.
- B. Increase the I.V. flow rate.
- C. Take the client's vital signs.
- D. Change the dressing.
Correct Answer: C
Rationale: Bright red drainage suggests active bleeding, so taking vital signs to assess for hemodynamic instability is the priority.
A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen at 2 L/min via nasal cannula. The nurse notes the client's oxygen saturation is 88%. What should the nurse do first?
- A. Increase the oxygen flow to 4 L/min.
- B. Notify the physician immediately.
- C. Encourage the client to perform deep breathing exercises.
- D. Reposition the client to a high Fowler's position.
Correct Answer: D
Rationale: Repositioning to a high Fowler's position optimizes lung expansion and improves oxygenation, which is the first non-invasive intervention to try for a COPD client with low oxygen saturation.
A client has a viral (coxsackie B) or trypanosomal (parasite) infection. The nurse should further assess the client for:
- A. Myocarditis.
- B. Myocardial infarction.
- C. Renal failure.
- D. Liver failure.
Correct Answer: A
Rationale: Coxsackie B and trypanosomal infections are associated with myocarditis, an inflammation of the heart muscle, which requires further assessment.
The nurse is teaching a client with diabetes mellitus about foot care. Which of the following instructions is most important?
- A. Wear open-toed shoes to promote air circulation.
- B. Inspect feet daily for cuts or sores.
- C. Soak feet in hot water to improve circulation.
- D. Apply lotion between the toes to prevent dryness.
Correct Answer: B
Rationale: Inspecting feet daily for cuts or sores is critical to prevent infections, a common complication in diabetes.