Nokea
A client with a history of chronic kidney disease is admitted with hyperphosphatemia. The nurse should expect to administer which of the following medications?
- A. Calcium carbonate.
- B. Ferrous sulfate.
- C. Vitamin D.
- D. Potassium chloride.
Correct Answer: A
Rationale: Calcium carbonate binds phosphate in the gut to manage hyperphosphatemia.
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A 10-year-old child has the following blood glucose readings during a 24-hour period. Which reading requires the most immediate intervention?
- A. 50 mg/dL.
- B. 100 mg/dL.
- C. 150 mg/dL.
- D. 200 mg/dL.
Correct Answer: A
Rationale: A blood glucose of 50 mg/dL indicates hypoglycemia, requiring immediate intervention to prevent neurological complications.
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.
Which of the following steps is the final step that is used during the physical assessment of the abdomen?
- A. Inspection
- B. Light palpation
- C. Deep palpation
- D. Percussion
Correct Answer: C
Rationale: The standard sequence for abdominal assessment is inspection, auscultation, percussion, and palpation (light then deep). Deep palpation is the final step to assess for organ size or abnormalities.
A client is receiving a tube feeding and has developed diarrhea, cramps, and abdominal distention. Which of the following interventions would be most appropriate? Select all that apply.
- A. Change the feeding apparatus every 24 hours.
- B. Use a higher volume of formula because the normal loss of the blood pressure.
- C. Slow the administration rate.
- D. Use a diluted formula, gradually increasing the volume and concentration.
- E. Anticipate changing to a lactose-free formula.
Correct Answer: A, C, D, E
Rationale: Changing the apparatus, slowing the rate, using diluted formula, and switching to lactose-free formula help manage diarrhea and distention.
A client with a history of heart failure is prescribed furosemide (Lasix). The nurse should monitor the client for which of the following electrolyte imbalances?
- A. Hyperkalemia.
- B. Hypokalemia.
- C. Hypernatremia.
- D. Hypocalcemia.
Correct Answer: B
Rationale: Furosemide, a loop diuretic, can cause hypokalemia by increasing potassium excretion in the urine.