Nokea
A client with a history of heart failure is admitted with pulmonary edema. The nurse should administer which of the following medications as prescribed? Select all that apply.
- A. Furosemide (Lasix).
- B. Digoxin (Lanoxin).
- C. Nitroglycerin.
- D. Morphine.
- E. Aspirin.
Correct Answer: A, C, D
Rationale: Furosemide reduces fluid overload, nitroglycerin decreases preload, and morphine relieves anxiety and preload in pulmonary edema.
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The nurse is assessing a neonate at 5 minutes after birth. The nurse records the Apgar score based on the findings in the chart A. The nurse compares these findings to the Apgar score obtained at birth, as determined by the findings in the chart B. What should the nurse do next?
- A. Notify the neonatologist on call.
- B. Continue to assess the neonate.
- C. Apply an oxygen mask.
- D. Rub the neonate’s extremities.
Correct Answer: B
Rationale: The neonate’s Apgar score has been improving since birth. (The birth score is 6; the current score is 9.) The nurse should continue to assess the neonate. There is no indication that oxygen is
needed since the color is improving, and stimulating the baby is not necessary as the he is now fl exing his extremities.
A client 6 weeks postpartum is asking the nurse about taking progesterone (Depo-Provera) for birth control. Which of the following should the nurse determine? Select all that apply.
- A. If the client has a sexually transmitted disease.
- B. How willing her husband is to have her take the drug.
- C. If the woman is experiencing postpartum depression.
- D. That the woman is not currently pregnant.
- E. If the woman is breast-feeding.
Correct Answer: C,D,E
Rationale: The nurse should assess for postpartum depression, pregnancy status, and breast-feeding, as these affect Depo-Provera's safety and efficacy. STDs and husband's willingness are not primary concerns.
The nurse is teaching a client with osteoporosis about calcium supplements. Which instruction is correct?
- A. Take calcium with a large meal.
- B. Avoid taking calcium with vitamin D.
- C. Take calcium at bedtime only.
- D. Split the dose if taking more than 500 mg.
Correct Answer: D
Rationale: Splitting doses above 500 mg improves absorption and reduces gastrointestinal side effects.
You will be administering packed red blood cells to your client. Which of the following principles should you apply to this blood administration?
- A. You must insure that the client has a patent intravenous catheter that is at least 20 gauge.
- B. You will need the help of another nurse prior to the administration of these packed red blood cells.
- C. The unit of packed red blood cells should start no more than 1 hour after it is picked up.
- D. You must remain with and monitor the client for at least 30 minutes after the transfusion begins.
Correct Answer: D
Rationale: Remaining with the client for at least 15-30 minutes after starting a blood transfusion is critical to monitor for acute transfusion reactions, such as hemolytic or allergic reactions.
The sense of hearing is assessed using which standardized test?
- A. The Taylor test
- B. The Rinne test
- C. The Babinski test
- D. The APGAR test
Correct Answer: B
Rationale: The Rinne test is a standardized test used to assess hearing by comparing air and bone conduction using a tuning fork.