Nokea
A home health nurse is managing care for an adolescent client with cystic fibrosis. Which of the following potential complications should the nurse consider when developing a nursing care plan? Select all that apply.
- A. Chronic hypoxemia
- B. Diabetes insipidus
- C. Frequent respiratory infections
- D. Obesity
- E. Vitamin deficiencies
Correct Answer: A,C,E
Rationale: Cystic fibrosis causes chronic hypoxemia , frequent infections , and vitamin deficiencies due to malabsorption. Diabetes insipidus is unrelated, and obesity is unlikely due to high metabolic demand.
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The nurse has received a prescription from the health care provider to administer 94 mg of methylprednisolone via IV push. The available vial contains 125 mg in 2 mL. Select the syringe containing the appropriate amount of medication to be administered.
- A. 1
- B. 2
- C. 3
- D. 4
Correct Answer: C
Rationale: Calculate: 94 mg ÷ 125 mg/2 mL = 1.504 mL. Syringe 3 (typically 1.5 mL) is closest. Syringes 1, 2, and 4 are not specified but assumed incorrect volumes.
As the nurse observes the student nurse during the administration of a narcotic analgesic IM injection, the nurse notes that the student begins to give the medication without first aspirating. What should the nurse do?
- A. Ask the student: 'What did you forget to do?'
- B. Stop. Tell me why aspiration is needed.
- C. Loudly state: 'You forgot to aspirate.'
- D. Walk up and whisper in the student's ear 'Stop. Aspirate. Then inject.'
Correct Answer: D
Rationale: This action is a direct threat to the client if the medication enters into the blood stream instead of the muscle. The purpose of aspiration with IM injections is to prevent the injection of the drug directly into the blood stream.
A client who is pregnant comes to the clinic for a first visit. The nurse gathers data about her obstetric history, which includes 3 year-old twins at home and a miscarriage 10 years ago. She is 8 weeks pregnant. Which description of her obstetric history is written correctly?
- A. Gravida 4 para 2
- B. Gravida 2 para 1
- C. Gravida 3 para 1
- D. Gravida 3 para 2
Correct Answer: C
Rationale: Gravida 3 para 1. Gravida is the number of pregnancies and Parity is the number of pregnancies that reach viability (not the number of fetuses). Thus, for this woman, she is now pregnant, had 2 prior pregnancies, and 1 viable birth (twins).
The nurse reinforces discharge teaching to a client who had a total knee replacement 4 days ago. Which client statement indicates the need for additional teaching?
- A. I have to give myself shots in the belly because my spouse is afraid of needles?
- B. I have to use a walker because I cant bear any weight on this knee yet.
- C. I will call my health care provider if I get short of breath or sore or swollen below my knee
- D. The raised toilet seat makes it easier for me to get on and off the toilet by myself.
Correct Answer: A
Rationale: Self-administered anticoagulant injections require confirmation of correct technique, not spousal fear, indicating misunderstanding. Walker use , symptom reporting , and toilet aids are correct.
A client with hyperkalemia is to receive an infusion of $250 \mathrm{~mL}$ of $20% glucose with 20 units of regular insulin. The rationale for this therapy is:
- A. Potassium elimination is enhanced.
- B. Potassium binds with the glucose and is excreted by the kidneys.
- C. Glucose uptake by the cell drives the potassium into the cell.
- D. Insulin lowers the potassium by lowering blood glucose.
Correct Answer: C
Rationale: Insulin facilitates glucose uptake by cells, which drives potassium into cells, lowering serum potassium levels in hyperkalemia.