Nokea
A client with a history of heart failure is prescribed enalapril (Vasotec). The nurse should monitor the client for which of the following adverse effects?
- A. Hyperkalemia.
- B. Hypotension.
- C. Weight loss.
- D. Tachycardia.
Correct Answer: A, B
Rationale: Enalapril, an ACE inhibitor, can cause hyperkalemia and hypotension.
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The nurse is teaching a client with gastroesophageal reflux disease (GERD) about lifestyle modifications. Which statement indicates understanding?
- A. I should eat large meals to avoid snacking.'
- B. I will sleep flat to relax my stomach.'
- C. I'll avoid lying down for 2 hours after eating.'
- D. I can drink orange juice with breakfast.'
Correct Answer: C
Rationale: Avoiding lying down for 2 hours after eating prevents acid reflux by keeping the stomach contents below the esophagus.
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.
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 multigravid client at 36 weeks' gestation who is visiting the clinic for a routine visit begins to sob and tells the nurse, 'My boyfriend has been beating me up once in a while since I became pregnant'”but I can't bring myself to leave him because I don't have a job and I don't know how I would take care of my other children.' Which of the following actions should be the priority by the nurse at this time?
- A. Contact a social worker for assistance and family counseling.
- B. Help the client make concrete plans for the safety of herself and her children.
- C. Tell the client and how anyone to hit her or her children.
- D. Provide the client with brochures on the statistics about violence against women.
Correct Answer: B
Rationale: Prioritizing safety planning protects the client and her children from further abuse.
A client with a history of pancreatitis is admitted with abdominal pain. The nurse should monitor the client for which of the following complications?
- A. Hypocalcemia.
- B. Hypernatremia.
- C. Hypotension.
- D. Hyperkalemia.
Correct Answer: A, C
Rationale: Pancreatitis can cause hypocalcemia (due to fat necrosis) and hypotension (due to fluid loss).