Nokea
A nurse in an emergency department is planning care for a client who is having an acute myocardial infarction (MI). Which of the following medications should the nurse plan to administer after the initial acute phase to manage the client's pain and anxiety?
- A. Nitroglycerin
- B. Aspirin
- C. Oxygen
- D. Morphine
Correct Answer: D
Rationale: Morphine is used for pain/anxiety management post-MI after acute interventions.
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A nurse is reviewing the laboratory test results from a client who has acute kidney injury (AKI). Which of the following electrolyte imbalances should the nurse expect?
- A. Hypophosphatemia
- B. Hypercalcemia
- C. Hyperkalemia
- D. Hypernatremia
Correct Answer: C
Rationale: Hyperkalemia is expected in AKI due to impaired renal potassium excretion.
A nurse is caring for a client who has heart failure and a prescription for digoxin 125 mcg orally daily. Digoxin is available in 0.25 mg/tablet form. How many tablets should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer: 0.5
Rationale: Calculation: 125 mcg = 0.125 mg; 0.125 mg ÷ 0.25 mg/tablet = 0.5 tablets
A nurse is preparing to instill 840 mL of enteral nutrition via a client's gastrostomy tube over a 24-hour period using an infusion pump. The nurse should set the infusion pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer: 35
Rationale: Calculation: 840 mL ÷ 24 hours = 35 mL/hr
The healthcare provider prescribes lactulose for a patient with hepatic encephalopathy. What will the nurse assess to determine the effectiveness of this medication?
- A. Decreased ammonia levels
- B. Relief of constipation
- C. Decreased liver enzymes
- D. Relief of abdominal pain
Correct Answer: A
Rationale: Lactulose works by reducing blood ammonia levels, which is its primary mechanism in treating hepatic encephalopathy.
The nurse is assessing for asterixis in a client with cirrhosis. How should the nurse assess for asterixis?
- A. Instruct the client to lean forward.
- B. Ask the client to extend the arms.
- C. Dorsiflex the client's foot.
- D. Measure the abdominal girth.
Correct Answer: B
Rationale: Asterixis (liver flap) is assessed by having patient extend arms and observing for involuntary flapping motions.