Nokea
A client with a diagnosis of multiple sclerosis is prescribed baclofen (Lioresal). The nurse should monitor the client for which of the following side effects?
- A. Hypertension.
- B. Drowsiness.
- C. Weight gain.
- D. Hyperglycemia.
Correct Answer: B
Rationale: Baclofen, a muscle relaxant, commonly causes drowsiness, which the nurse should monitor in clients with multiple sclerosis.
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A nurse is relieving the triage nurse in the labor and delivery unit who is going to lunch. The report indicates that there are three clients having their vital signs assessed and a fourth client is on her way to the unit from the emergency department. In which order of priority should the nurse manage these clients?
- A. The client with clear vesicles and brown vaginal discharge at 16 weeks' gestation.
- B. The client with right lower quadrant pain at 10 weeks' gestation.
- C. The client who is at term and has had no fetal movement for 2 days.
- D. The client from the emergency department at term and screaming loudly because of labor contractions.
Correct Answer: C,D,A,B
Rationale: The client with no fetal movement at term is the highest priority due to the risk of fetal distress. The client in active labor requires immediate attention. Vesicles and discharge suggest possible infection, and right lower quadrant pain may indicate ectopic pregnancy, both serious but less urgent.
The nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following laboratory values should the nurse monitor closely?
- A. Serum potassium.
- B. Serum sodium.
- C. Blood urea nitrogen.
- D. Blood glucose.
Correct Answer: D
Rationale: TPN contains high glucose concentrations, requiring close monitoring of blood glucose to prevent hyperglycemia.
A client with a history of breast cancer is prescribed anastrozole (Arimidex). The nurse should monitor the client for which of the following adverse effects?
- A. Bone loss.
- B. Hyperglycemia.
- C. Hypertension.
- D. Weight gain.
Correct Answer: A
Rationale: Anastrozole, an aromatase inhibitor, can cause bone loss, increasing osteoporosis risk.
A nurse is caring for a client with a suspected myocardial infarction. Which of the following laboratory results should the nurse prioritize?
- A. Elevated troponin levels
- B. Decreased hemoglobin
- C. Increased potassium
- D. Elevated white blood cell count
Correct Answer: A
Rationale: Troponin is a specific marker for myocardial damage and is critical in diagnosing myocardial infarction. Other results are less specific to this condition.
Which of the following compensatory actions by the body would occur if a client were in respiratory acidosis?
- A. Excretion of bicarbonate (HCO₃⁻) by the kidneys.
- B. Retention of HCO₃⁻ by the kidneys.
- C. Increase in respiratory rate by the lungs.
- D. Decrease in respiratory rate by the lungs.
Correct Answer: B, C
Rationale: In respiratory acidosis, the body compensates by retaining bicarbonate (HCO₃⁻) in the kidneys and increasing respiratory rate to eliminate excess CO2.