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A male client is admitted to the emergency department while vomiting dark brown, foul- smelling emesis. He reports having a surgical repair of a recurrent inguinal hernia a week ago and is troubled by intense abdominal pain. After finding that his bowel sounds are hyperactive, which prescription should the nurse implement first?
- A. Place an indwelling urinary catheter and attach a bedside drainage unit.
- B. Send the client to x-ray for a flat plate of the abdomen.
- C. Insert a nasogastric tube (NGT) and attach to low intermittent suction.
- D. Give a prescribed analgesic for temperature above 101° F (38.3°C).
Correct Answer: C
Rationale: An NGT decompresses the stomach, addressing potential bowel obstruction indicated by vomiting and hyperactive bowel sounds.
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A client with hyperparathyroidism reports a sudden onset of severe flank pain. Which intervention should the nurse include in the client's plan of care?
- A. Implement seizure precautions.
- B. Begin straining all urine.
- C. Administer a PRN dose of a laxative.
- D. Initiate cardiac telemetry.
Correct Answer: B
Rationale: Straining urine checks for kidney stones, likely causing flank pain in hyperparathyroidism, prioritizing over other interventions.
A client with heart failure (HF) returns to the clinic two weeks after adjustments were made to the prescribed cardiac glycoside, diuretic, and potassium supplement. The client's lungs are clear, heart rate is 58 beats/minute, and serum potassium level is 2.9 mEq/L (2.9 mmol/L). Which action is most important for the nurse to implement?
- A. Compare the weight with what it was at last visit.
- B. Report serum potassium to healthcare provider.
- C. Review the dietary history from the past week.
- D. Check the pretibial areas and ankles for edema.
Correct Answer: B
Rationale: Reporting hypokalemia (2.9 mEq/L) is critical to prevent arrhythmias, especially with cardiac glycosides.
A client with type 2 diabetes mellitus (DM) is admitted to the hospital for uncontrolled DM. Insulin therapy is initiated with an initial dose Isophane suspension insulin at 0800. At 1600, the client reports having diaphoresis, rapid heartbeat, and feeling shaky. Which should the nurse do first?
- A. Assess the client's oxygen saturation level.
- B. Determine the client's current glucose level
- C. Give the client one-half cup of fruit juice.
- D. Give the client skim milk and crackers.
Correct Answer: B
Rationale: Checking glucose confirms hypoglycemia, indicated by symptoms, guiding appropriate treatment.
The nurse includes the problem of 'Risk for infection' in the plan of care for a client with myelosuppression. Which laboratory value of care provides the greatest support for this nursing problem?
- A. Hematocrit of 33% (0.33 volume fraction).
- B. White blood cell count of 1,500/mm3 (1.5 x 10°)
- C. Hemoglobin of 10 g/dl (6.21 mmol/L)
- D. Red blood cell count of 3.5 x 10l(3.5 x 10°).
Correct Answer: B
Rationale: A low white blood cell count (1,500/mm³) indicates leukopenia, increasing infection risk, unlike other values.
The healthcare provider prescribes cefazolin 800 mg IM every six hours. The available vial is labeled, 'Cefazolin 1 gram,' and the instructions for reconstitution state, For IM use add 2.5 mL sterile water for Injection to provide a total volume of 3.0 mL. After reconstitution, the solution contains how many mg/mL? Enter numeric value only. If rounding is required, round to the nearest whole number.)
Correct Answer: 333
Rationale: One gram (1000 mg) reconstituted in 3.0 mL yields a concentration of 1000 mg / 3 mL = 333.33 mg/mL, rounded to 333 mg/mL.