Nokea
A client with a history of cirrhosis is admitted with ascites. The nurse should include which of the following in the plan of care?
- A. Administer spironolactone as prescribed.
- B. Restrict sodium intake.
- C. Encourage a high-carbohydrate diet.
- D. Limit fluid intake.
Correct Answer: A, B
Rationale: Spironolactone and sodium restriction reduce fluid retention in ascites.
You may also like to solve these questions
A client with a history of gout is prescribed probenecid. The nurse should instruct the client to:
- A. Increase fluid intake.
- B. Avoid aspirin.
- C. Take the medication with meals.
- D. Stop the medication if pain resolves.
Correct Answer: A, B
Rationale: Increased fluid intake prevents kidney stones, and aspirin can reduce probenecid's effectiveness.
A client with a history of depression is prescribed mirtazapine (Remeron). The nurse should monitor the client for which of the following adverse effects?
- A. Weight gain.
- B. Hypoglycemia.
- C. Bradycardia.
- D. Hypotension.
Correct Answer: A
Rationale: Mirtazapine commonly causes weight gain.
The nurse is caring for a client with a spinal cord injury at C5. Which complication should the nurse monitor for?
- A. Respiratory distress
- B. Urinary retention
- C. Pressure ulcers
- D. All of the above
Correct Answer: D
Rationale: A C5 spinal cord injury can cause respiratory distress (diaphragm impairment), urinary retention (loss of bladder control), and pressure ulcers (immobility), requiring comprehensive monitoring.
A client with a history of burns is admitted with a 40% total body surface area injury. The nurse should prioritize which of the following interventions?
- A. Initiate fluid resuscitation.
- B. Administer prophylactic antibiotics.
- C. Apply ice to the burns.
- D. Cover the burns with dry gauze.
Correct Answer: A
Rationale: Fluid resuscitation is the priority to prevent hypovolemic shock in extensive burns.
When giving a client a tube feeding the nurse should:
- A. Warm the feeding solution before administration.
- B. Place the client in a left side-lying position.
- C. Aspirate residual gastric contents before the feeding and discard.
- D. Verify position of the tube before beginning feeding.
Correct Answer: D
Rationale: Verifying tube position (e.g., via pH testing or X-ray) is critical to ensure safe administration and prevent aspiration.