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A client with increased intracranial pressure is receiving Mannitol and Lasix. The nurse recognizes that these two drugs are given to reverse which effect?
- A. Energy failure
- B. Excessive intracellular calcium accumulation
- C. Cellular edema
- D. Excessive glutamate release
Correct Answer: C
Rationale: Mannitol and Lasix are diuretics that reduce cerebral edema by drawing fluid out of swollen brain cells, decreasing intracranial pressure.
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A client's serum sodium level is 113 mEq/L. The nurse would expect which findings upon assessment?
- A. headache, confusion, muscle weakness, fatigue
- B. hypertension, muscle cramps, respiratory depression
- C. cardiac arrhythmia, tetany, tachycardia
- D. confusion, nystagmus, tetany, hallucinations
Correct Answer: A
Rationale: Severe hyponatremia (113 mEq/L) causes neurological symptoms like headache, confusion, muscle weakness, and fatigue due to cerebral edema.
If a client with psoriasis is to begin NB-UVB phototherapy, how long should the initial treatment be?
- A. 30 seconds to 1 minute
- B. 1 to 2 minutes
- C. 5 to 10 minutes
- D. 15 to 20 minutes
Correct Answer: A
Rationale: Initial NB-UVB phototherapy starts with 30 seconds to 1 minute (A) to assess skin tolerance and prevent burns. Longer durations (B, C, D) are used in subsequent sessions.
Which roommate would be most suitable for the 6-year-old male with a fractured femur in Russell's traction?
- A. 16-year-old female with scoliosis
- B. 12-year-old male with a fractured femur
- C. 10-year-old male with sarcoma
- D. 6-year-old male with osteomylitis
Correct Answer: B
Rationale: A 12-year-old male with a similar condition provides age-appropriate companionship and shared care needs.
A client is hospitalized with signs of transplant rejection following a recent renal transplant. Assessment of the client would be expected to reveal:
- A. A weight loss of 2 pounds in 1 day
- B. A serum creatinine 1.25 mg/dL
- C. Urinary output of 50 mL/hr
- D. Rising blood pressure
Correct Answer: D
Rationale: Rising blood pressure is a sign of renal transplant rejection due to impaired kidney function and fluid retention.
The nurse is assessing an ECG strip of a 42-year-old client and finds a regular rate greater than 100, a normal QRS complex, a normal P wave in front of each QRS, a PR interval between 0.12 and 0.20 seconds, and a P: QRS ratio of 1:1. What is the nurse's interpretation of this rhythm?
- A. Premature atrial complex
- B. Sinus tachycardia
- C. Atrial flutter
- D. Supraventricular tachycardia
Correct Answer: B
Rationale: A regular rate >100 with normal P waves, QRS complexes, and PR interval indicates sinus tachycardia, a common response to stress, fever, or hypoxia.