Nokea
Laboratory results
Sodium
136-145 mEq/L
(136-145 mmol/L) 126 mEq/L
(126 mmol/L)
Potassium
3.5-5.0 mEq/L
(3.5-5.0 mmol/L) 4.8 mEq/L
(4.8 mmol/L)
Calcium
9.0–10.5 mg/dL
(2.25–2.62 mmol/L) 9.0 mg/dL
(2.25 mmol/L)
A client with heart failure has gained 5 lb (2.26 kg) over the last 3 days. The nurse reviews the client's blood laboratory results. Based on this information, what medication administration does the nurse anticipate?
- A. 0.45% sodium chloride IV
- B. Calcium gluconate
- C. Furosemide
- D. Sodium polystyrene sulfonate
Correct Answer: C
Rationale: Weight gain in heart failure suggests fluid retention. Furosemide (C), a diuretic, is anticipated to reduce fluid overload. Sodium chloride (A) worsens fluid retention, and calcium gluconate (B) and sodium polystyrene (D) address other conditions.
You may also like to solve these questions
The nurse administers subcutaneous insulin lispro at 0730 to a client as prescribed and the client consumes breakfast 30 minutes later. At what time is the client at highest risk for experiencing insulin-related hypoglycemia?
- A. 830
- B. 1100
- C. 1330
- D. 1500
Correct Answer: B
Rationale: Insulin lispro peaks 1-2 hours after administration, so 1100 (B), about 3.5 hours post-injection, is the highest risk time for hypoglycemia.
The nurse is caring for a client who has a prescription for ampicillin 1.5 g IV in 100 mL of 0.9% sodium chloride to be administered over 30 minutes. The nurse has tubing with a drop factor of 15 available. How many gtts/min should the client receive? Record your answer using a whole number.
Correct Answer: 50
Rationale: Flow rate = (100 mL / 30 min) x (15 gtts/mL) = 50 gtts/min (A).
The nurse is preparing to administer ear drops to a 5-year-old client. Which of the following actions should the nurse take?
- A. Pull the client's pinna upward and back.
- B. Help the client sit upright with the chin tilted down.
- C. Touch the dropper to the entrance of the ear canal.
- D. Remove the medication from the refrigerator just before use.
Correct Answer: A
Rationale: Pulling the pinna upward and back (A) straightens the ear canal in children over 3. Sitting with chin down (B), touching the canal (C), or cold drops (D) are incorrect.
The nurse is collecting data from a 10-year-old client during a routine physical examination. Which of the following actions should the nurse take? Select all that apply.
- A. Use correct anatomical terminology while reinforcing teaching about self-care.
- B. Conduct a head-to-toe examination in the same sequence as an adult examination.
- C. Explain the purpose of the examination equipment and any procedures to the client.
- D. Offer the client a gown and allow the client to keep the underwear on during the examination.
- E. Ask the accompanying parent to rate and describe any pain the client may be experiencing.
Correct Answer: A, C, D
Rationale: Using anatomical terminology (A) promotes understanding. Explaining equipment and procedures (C) reduces anxiety. Offering a gown and allowing underwear (D) respects privacy. Adult examination sequences (B) may not suit pediatric needs, and parents rating pain (E) may not accurately reflect the child's experience.
The nurse is reinforcing home care instructions to a client newly diagnosed with osteomalacia. Which of the following client statements indicate proper understanding of teaching? Select all that apply.
- A. I will avoid foods high in calcium and phosphorus.'
- B. I will avoid going outside on sunny days.'
- C. I will eat foods that are fortified with vitamin D.'
- D. I will engage in physical activity to increase bone strength.'
- E. I will use a cane to help me get around better.'
Correct Answer: C, D
Rationale: Vitamin D-rich foods (C) and physical activity (D) improve bone health in osteomalacia. Avoiding calcium/phosphorus (A), sunlight (B), or using a cane (E) are incorrect or unnecessary.