Nokea
A client with a history of peptic ulcer disease is admitted with hematemesis. The nurse should prioritize which of the following interventions?
- A. Administer pantoprazole intravenously.
- B. Insert a nasogastric tube.
- C. Administer vitamin K.
- D. Position the client supine.
Correct Answer: A
Rationale: Intravenous pantoprazole reduces acid production and stabilizes bleeding in peptic ulcer disease.
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How many units of heparin would you administer subcutaneously using the below information? Doctor's order: 6,500 units of heparin subcutaneously Medication label: 4,500 units in one mL
- A. 1.4 mL
- B. 1.5 mL
- C. 1.475 mL
- D. 1.425 mL
- E. 1.375 mL
Correct Answer: A
Rationale: To calculate: 6,500 units ÷ 4,500 units/mL = 1.444 mL, rounded to 1.4 mL for practical administration.
A client with a new colostomy asks the nurse how to prevent skin irritation around the stoma. What is the best response by the nurse?
- A. Apply petroleum jelly around the stoma daily.'
- B. Clean the area with alcohol wipes before applying the pouch.'
- C. Ensure the skin barrier fits snugly and clean with mild soap.'
- D. Change the pouch only once a week.'
Correct Answer: C
Rationale: A snug-fitting skin barrier and cleaning with mild soap prevent skin irritation by protecting the peristomal skin and maintaining hygiene without causing trauma.
Which tool or scale would you use for a focused neurological assessment of your client?
- A. The Lazarus Cognitive Appraisal Scale
- B. The Hamilton Rating Scale
- C. The McGill Scale
- D. The Rancho Los Amigos Scale
Correct Answer: D
Rationale: The Rancho Los Amigos Scale is used for assessing levels of consciousness and cognitive recovery in patients with brain injuries, ideal for a focused neurological assessment.
A client with acute pancreatitis is put on nothing-by-mouth status, with the intent of not stimulating the pancreas. The client is prescribed an I.V. infusion of dextrose 5% in half-normal saline solution at 120 mL/hour. After 3 days of this regimen, the nurse should observe the client for which of the following metabolic conditions?
- A. Ketosis.
- B. Hyperglycemia.
- C. Metabolic syndrome.
- D. Lactic acidosis.
Correct Answer: B
Rationale: Dextrose 5% infusion can lead to hyperglycemia, especially in a client with acute pancreatitis, requiring monitoring.
The nurse establishes the goal of preventing the development of a stress ulcer in a burn client. Which of the following interventions would most likely contribute to the achievement of this goal?
- A. Implementing relaxation exercises.
- B. Administering a sedative as needed.
- C. Administering prophylactic antacids or histamine-2 receptor antagonists.
- D. Monitoring the client's nutritional status closely.
Correct Answer: C
Rationale: Prophylactic antacids or H2 receptor antagonists reduce gastric acid, preventing stress ulcers in burn patients, who are at high risk due to stress response.