Nokea
A client with acute renal failure is at risk for:
- A. Infection.
- B. Hypoglycemia.
- C. Hypernatremia.
- D. Bone fractures.
Correct Answer: A
Rationale: Infection risk is high due to impaired immune response and dialysis access.
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A client has been in an automobile accident and the nurse is assessing the client for possible pneumothorax. The nurse should assess the client for:
- A. Sudden, sharp chest pain.
- B. Wheezing breath sounds over affected side.
- C. Hemoptysis.
- D. Cyanosis.
Correct Answer: A
Rationale: Sudden, sharp chest pain is a hallmark of pneumothorax due to pleural irritation. Wheezing, hemoptysis, and cyanosis are less specific or occur later.
The nurse is caring for a client who has been diagnosed with macular degeneration. Which of the following images represent the visual field of a client with macular degeneration?
- A. Qstn 14-A Visual.png
- B. Qstn 14-B Visual.png
- C. Qstn 14-C Visual.png
- D. Qstn 14-D Visual.png
Correct Answer:
Rationale: Macular degeneration causes central vision loss, so the image would show a blurred or dark central area with intact peripheral vision. Specific image selection is not applicable here due to lack of image options.
The nurse is planning a staff development conference about medication safety. Which of the following medications should have a second medication check prior to administration? Select all that apply.
- A. heparin infusion
- B. regular insulin
- C. 0.9% sodium chloride (normal saline) flush
- D. patient-controlled analgesia (PCA)
- E. oxytocin infusion
- F. total parenteral nutrition
Correct Answer: A,B,D,E,F
Rationale: High-risk medications like heparin, insulin, PCA, oxytocin, and TPN require a second check to prevent errors.
The nurse is reviewing a care plan for a client with chronic pain receiving morphine sulfate. Which of the following aspects in the plan of care require revision?
- A. Adjust the physician's order based on the client's pain level
- B. Ensure naloxone is always available
- C. Check the client's blood pressure before administering morphine sulfate
- D. Provide a high-fiber diet
Correct Answer: A
Rationale: Nurses cannot adjust physician orders independently; this requires clarification or a new order from the provider.
Atropine sulfate (Atropine) is contraindicated in all but which one of the following clients?
- A. A client with diabetes.
- B. A client with glaucoma.
- C. A client with urine retention.
- D. A client with bowel obstruction.
Correct Answer: A
Rationale: Atropine is contraindicated in glaucoma (increases intraocular pressure), urine retention (worsens retention), and bowel obstruction (reduces motility). It is not contraindicated in diabetes, as it has no direct effect on glucose metabolism.