Nokea
A client with a history of cirrhosis is admitted with esophageal varices. The nurse should monitor the client for which of the following complications?
- A. Hematemesis.
- B. Hypotension.
- C. Fever.
- D. Constipation.
Correct Answer: A, B
Rationale: Esophageal varices can rupture, causing hematemesis and hypotension.
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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.
A family has been notified that their son is brain dead, and the physician has discussed the possibility of donating organs. The nurse should collaborate with the physician to contact which referral source that is responsible for organ recovery in the United States?
- A. Organ and Tissue Procurement Organizations.
- B. American Transplant Association.
- C. American Hospice Foundation.
- D. American Association of Critical-Care Nurses.
Correct Answer: A
Rationale: Organ and Tissue Procurement Organizations are responsible for coordinating organ recovery in the United States, as they manage the donation process and ensure compliance with regulations.
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.
An adult client has bacterial conjunctivitis. What should the nurse teach him to do? Select all that apply.
- A. Use warm saline soaks four times per day to remove crusting.
- B. Apply topical antibiotic without touching the tip of the tube to his eye.
- C. Wash his hands after touching his eyes.
- D. Avoid touching his eyes.
- E. Observe isolation procedures and confine himself to his bedroom until the redness in the eye disappears.
Correct Answer: A,B,C,D
Rationale: Warm saline soaks, careful antibiotic application, hand washing, and avoiding eye contact prevent spread and promote healing. Isolation is unnecessary unless specified.
A client with a history of type 2 diabetes mellitus is prescribed metformin (Glucophage). The nurse should instruct the client to report which of the following side effects immediately?
- A. Mild nausea.
- B. Metallic taste.
- C. Lactic acidosis symptoms.
- D. Weight gain.
Correct Answer: C
Rationale: Lactic acidosis is a rare but serious side effect of metformin, requiring immediate reporting of symptoms like muscle pain or weakness.