Nokea
A nurse in a provider's office is reviewing the laboratory results of a client who takes furosemide for hypertension. The nurse notes that the client's potassium level is 3.3 mEq/L. The nurse should monitor the client for which of the following complications?
- A. Hypertension
- B. Hyperkalemia
- C. Cardiac dysrhythmias
- D. Pulmonary edema
Correct Answer: C
Rationale: The correct answer is C: Cardiac dysrhythmias. Furosemide is a loop diuretic that can lead to hypokalemia, which is a potassium deficiency. A potassium level of 3.3 mEq/L is below the normal range (3.5-5.0 mEq/L) and can increase the risk of cardiac dysrhythmias due to the role potassium plays in maintaining the heart's electrical activity. Hypertension (A) is not directly related to low potassium levels. Hyperkalemia (B) is the opposite of what the client is experiencing. Pulmonary edema (D) is not typically associated with low potassium levels.
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A nurse is teaching a newly licensed nurse about gynecological examination. Which of the following information should the nurse include in the teaching?
- A. The urethral orifice is assessed by separating the labia minora.
- B. The cervix should be palpated for size.
- C. The vagina should be inspected without a speculum.
- D. The clitoris should be massaged during examination.
Correct Answer: A
Rationale: Correct Answer: A
Rationale: The urethral orifice is located between the clitoris and vaginal opening, so separating the labia minora is necessary to assess it. This step ensures proper assessment of the urinary system and helps detect any abnormalities.
Summary of Incorrect Choices:
B: Palpating the cervix for size is not a standard part of a gynecological examination; it may cause discomfort and is unnecessary unless indicated for specific medical reasons.
C: Inspecting the vagina without a speculum is not recommended as it may not provide a clear view of the vaginal walls and cervix, potentially missing important findings.
D: Massaging the clitoris is not a part of a gynecological examination and is inappropriate; it may be uncomfortable for the patient and is not relevant to the assessment.
A nurse is performing an ECG on a client who is experiencing chest pain. Which of the following statements should the nurse make?
- A. I will need to apply electrodes to your chest and extremities.
- B. You may feel some discomfort during the procedure.
- C. The procedure will take about an hour.
- D. We need to monitor your heart rate continuously after the procedure.
Correct Answer: A
Rationale: Correct Answer: A
Rationale: Applying electrodes to the chest and extremities is necessary for a complete ECG recording. Electrodes are placed strategically to capture electrical activity of the heart. This statement informs the client about the procedure and ensures accurate results. Other options are incorrect because discomfort during the procedure is subjective and not guaranteed (B), an ECG typically takes only a few minutes, not an hour (C), and continuous heart rate monitoring is not required post-procedure unless indicated by the results (D).
A nurse is preparing to initiate a transfusion of packed RBC for a client who has anemia. Which of the following actions should the nurse take?
- A. Check the client's vital signs every 15 min during the transfusion.
- B. Obtain a blood pressure reading every 30 minutes during the transfusion.
- C. Start the transfusion at a rapid rate to improve hemoglobin levels.
- D. Check the client's vital signs every hour during the transfusion.
Correct Answer: A
Rationale: The correct answer is A: Check the client's vital signs every 15 min during the transfusion. This is crucial to monitor for any signs of transfusion reaction, such as fever, chills, or hypotension. Vital signs should be closely monitored initially and then at regular intervals to ensure the client's safety. Checking every 15 minutes allows for early detection and prompt intervention if any adverse reactions occur.
Choice B is incorrect because obtaining a blood pressure reading every 30 minutes is not as frequent as checking vital signs every 15 minutes, which is necessary for early detection of adverse reactions.
Choice C is incorrect as starting the transfusion at a rapid rate can lead to adverse reactions like fluid overload or hemolysis. Transfusions should be started at a slow rate to minimize these risks.
Choice D is incorrect because checking vital signs every hour is not frequent enough to detect early signs of transfusion reactions. Regular monitoring every 15 minutes is recommended for safety.
A nurse is providing discharge teaching to a client who has a new arteriovenous fistula in the right forearm. Which of the following manifestations should the nurse include in the teaching as a possible indication of venous insufficiency?
- A. Cold and numbness distal to the fistula site
- B. Swelling around the fistula
- C. Bleeding from the fistula
- D. Pain at the site of fistula
Correct Answer: A
Rationale: The correct answer is A: Cold and numbness distal to the fistula site. This is indicative of venous insufficiency, which can occur when the arteriovenous fistula is not functioning properly. When there is inadequate blood flow through the fistula, it can result in reduced circulation to the distal part of the arm, leading to coldness and numbness. Swelling around the fistula (choice B) is more commonly associated with infection or inadequate drainage. Bleeding from the fistula (choice C) is a potential complication but not a typical manifestation of venous insufficiency. Pain at the site of the fistula (choice D) may indicate infection or clotting issues rather than venous insufficiency.
A nurse is teaching a client about the causes of osteoporosis. The nurse should include which of the following types of medication therapy as a risk factor for osteoporosis?
- A. Aspirin therapy
- B. Calcium supplements
- C. Estrogen therapy
- D. Thyroid hormones
Correct Answer: D
Rationale: The correct answer is D: Thyroid hormones. Excessive use of thyroid hormones can lead to osteoporosis by increasing bone turnover and reducing bone mineral density. Thyroid hormones can interfere with the normal process of bone formation and resorption, leading to weakened bones. Aspirin therapy (A) is not a risk factor for osteoporosis. Calcium supplements (B) are actually recommended to prevent osteoporosis. Estrogen therapy (C) is also not a risk factor; in fact, estrogen helps to maintain bone density.