Nokea
A nurse is assessing a client and discovers the infusion pump with the client's total parenteral nutrition (TPN) solution is not infusing. The nurse should monitor the client for which of the following clinical manifestations?
- A. Fever and chills
- B. Hypertension and crackles
- C. Excessive thirst and urination
- D. Shakiness and diaphoresis
Correct Answer: D
Rationale: These are signs of hypoglycemia from sudden TPN interruption.
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A client with a history of angina is being admitted to the emergency department with a suspected myocardial infarction (MI). Which of the following findings will help the nurse distinguish stable angina from an MI?
- A. MI only occurs with exertion.
- B. Stable angina can occur for longer than 30 minutes.
- C. Stable angina can be relieved with rest and nitroglycerin.
- D. The pain of an MI lasts less than 15 minutes.
Correct Answer: C
Rationale: Stable angina is usually relieved within 3-5 minutes by rest or nitroglycerin, while MI pain is more prolonged and severe and not relieved by these measures.
A nurse is preparing to administer intermittent lipid emulsion and notes a layer of fat floating in the IV solution bag. Which action should the nurse take?
- A. Shake the bag to mix the fat.
- B. Administer the bag of solution.
- C. Return the bag to the pharmacy.
- D. Turn the bag upside down one time.
Correct Answer: C
Rationale: Fat separation indicates instability; solution should be returned to pharmacy as it could cause fat embolism.
A client is admitted to the emergency room with renal calculi. Upon assessment, which of the following findings should the nurse expect?
- A. Bradycardia
- B. Bradypnea
- C. Severe pain
- D. Nocturia
Correct Answer: C
Rationale: Severe pain (renal colic) is the most common symptom of renal calculi, caused by the stone moving and blocking the ureter.
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.
A nurse is caring for a client who has a deep vein thrombosis and is prescribed heparin by continuous IV infusion at 1,200 units/hr. Heparin is available in a concentration of 25,000 units in 500 mL D5W. The nurse should set the IV pump to deliver how many mL/hr? (Round the answer to the nearest tenth/whole number. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer: 24
Rationale: Calculation: (1,200 units/hr ÷ 25,000 units) × 500 mL = 24 mL/hr