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A client with acute respiratory distress syndrome (ARDS) has fine crackles at lung bases and the respirations are shallow at a rate of 28 breaths/minute. The client is restless and anxious. In addition to monitoring the arterial blood gas results, the nurse should do which of the following? Select all that apply.
- A. Monitor serum creatinine and blood urea nitrogen levels.
- B. Administer a sedative.
- C. A. Administer humidified oxygen.
- D. Auscultate the lungs.
Correct Answer: C,D
Rationale: Administering humidified oxygen (C) improves oxygenation in ARDS. Auscultating lungs (D) monitors crackles and ventilation. Creatinine/BUN monitoring is unrelated to acute respiratory status. Sedatives may depress respiration.
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The emergency department (ED) nurse cares for a client receiving prescribed warfarin and reports dizziness, black tarry stools, and bloody gums. The international normalized ratio (INR) returns at 5 (0.9-1.2 seconds). The nurse anticipates the primary healthcare provider (PHCP) will prescribe which blood product?
- A. Packed red blood cells (PRBCs)
- B. Platelets
- C. Granulocytes
- D. Fresh frozen plasma (FFP)
Correct Answer: D
Rationale: An INR of 5 indicates significant anticoagulation from warfarin, increasing bleeding risk (evidenced by tarry stools and bloody gums). FFP provides clotting factors to reverse warfarin’s effects. PRBCs address anemia, platelets address thrombocytopenia, and granulocytes treat infections, none of which are primary here.
A client's serum ammonia level is elevated, and the physician orders 30 mL of lactulose (Cephulac). Which of the following is an adverse effect of this drug?
- A. Increased urine output.
- B. Improved level of consciousness.
- C. Increased bowel movements.
- D. Nausea and vomiting.
Correct Answer: C
Rationale: Lactulose promotes bowel movements (C) to excrete ammonia, a common adverse effect. Urine output (A) and consciousness (B) are not adverse effects. Nausea (D) is less common.
A client has an amylase level of 450 units/L and lipase level of 659 units/L. The client has mid-epigastric pain with nausea. What assessment helps the nurse to determine severity of the client's condition?
- A. Ranson's criteria.
- B. Vital signs.
- C. Urine output.
- D. Glasgow Coma Scale.
Correct Answer: A
Rationale: Ranson's criteria (A) assess pancreatitis severity based on lab and clinical findings (e.g., age, white blood cell count, glucose). Vital signs (B) and urine output (C) are important but less specific. Glasgow Coma Scale (D) is for neurological assessment, not pancreatitis.
A client with breast cancer has abdominal bloating and cramping with no bowel movement for 5 days. She says she usually has a bowel movement every day after her morning coffee. Bowel sounds are present in all four quadrants. She received 80 mg of doxorubicin hydrochloride (Adriamycin) 10 days ago. The nurse should contact the health care provider to request an order for which of the following?
- A. A Fleet enema to stimulate peristalsis.
- B. A soapsuds enema until clear.
- C. A small-volume tap water enema to stimulate a bowel movement; then evaluate the need for daily stool softeners.
- D. A daily stool softener for constipation and a mild opioid for abdominal discomfort.
Correct Answer: C
Rationale: A small-volume tap water enema is a gentle, effective intervention to stimulate a bowel movement, followed by evaluation for stool softeners to prevent recurrence, addressing chemotherapy-related constipation.
A postmenopausal client is scheduled for a bone-density scan. To plan for the client's test, what should the nurse communicate to the client?
- A. Request that the client remove all metal objects on the day of the scan.
- B. Instruct the client to consume foods and beverages with a high content of calcium for 2 days before the test.
- C. Inform the client that she will need to ingest 600 mg of calcium gluconate by mouth for 2 weeks before the test.
- D. Tell the client that she should report any significant pain to her physician at least 2 days before the test.
Correct Answer: A
Rationale: Metal objects can interfere with the bone-density scan, so they must be removed. Calcium intake or pain reporting is not required for the test.