A client with pulmonary edema is ordered IV hydrocortisone (Solu-Cortef) 40 mg b.i.d. Which laboratory value would the nurse expect to see as a result of this therapy?
- A. elevated magnesium
- B. lowered magnesium
- C. elevated glucose
- D. lowered glucose
Correct Answer: C
Rationale: Hydrocortisone, a corticosteroid, increases blood glucose by promoting gluconeogenesis. Magnesium levels are not primarily affected.
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The nurse is doing hourly rounds when he finds a 73-year-old female client unconscious on the floor next to the bed. An incident report must be filled out. What is the best statement for the nurse to write on the incident report?
- A. Client fell out of bed at some point between 0700 and 0800.'
- B. Client was found unresponsive on floor next to the bed.'
- C. Client likely slipped on the floor and hit her head.'
- D. Client attempted to ambulate without assistance and fell.'
Correct Answer: B
Rationale: The incident report should state objective findings: 'Client was found unresponsive on floor next to the bed.' Speculative statements (slipped, attempted to ambulate) are inappropriate.
Acticoat (silver nitrate) dressings are applied to the legs of a client with deep partial thickness burns. The nurse should:
- A. Change the dressings once per shift
- B. Moisten the dressing with sterile water
- C. Change the dressings only when they become soiled
- D. Moisten the dressing with normal saline
Correct Answer: B
Rationale: Acticoat dressings require moistening with sterile water to activate the silver release, which provides antimicrobial effects for burn wounds.
The rationale for inserting a French catheter every hour for the client with epidural anesthesia is:
- A. The bladder fills more rapidly because of the medication used for the epidural.
- B. Her level of consciousness is such that she is in a trancelike state.
- C. The sensation of the bladder filling is diminished or lost.
- D. She is embarrassed to ask for the bedpan that frequently.
Correct Answer: C
Rationale: Epidural anesthesia can reduce bladder sensation, necessitating frequent catheterization to prevent overdistension.
The physician has ordered an infusion of Osmitrol (mannitol) for a client with increased intracranial pressure. Which finding indicates the direct effectiveness of the drug?
- A. Increased pulse rate
- B. Increased urinary output
- C. Decreased diastolic blood pressure
- D. Increased pupil size
Correct Answer: B
Rationale: Mannitol is an osmotic diuretic that reduces intracranial pressure by increasing urinary output, drawing fluid out of the brain tissue.
The nurse is supervising a student nurse on the oncology unit who is providing care for a client with neutropenic precautions. Which action by the student nurse requires intervention by the supervising nurse?
- A. Vital signs, including temperature, are monitored every 4 hours.
- B. The student nurse inspects the client's mouth at least every 8 hours.
- C. The student nurse delivers a potted plant to the room sent by the client's family.
- D. The student nurse washes her hands before performing client care or touching client belongings.
Correct Answer: C
Rationale: Potted plants pose an infection risk (e.g., mold) for neutropenic clients and are prohibited. Other actions are appropriate.
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