Nokea
A nurse is assessing a client who recently had a myocardial infarction. Which of the following findings indicates that the client might be developing pulmonary edema?
- A. Excessive somnolence
- B. Epistaxis
- C. Pink
- D. frothy sputum
- E. Tachypnea
Correct Answer: C
Rationale: The correct answer is C: Pink frothy sputum. This finding indicates pulmonary edema, which is characterized by fluid accumulation in the lungs. The pink color indicates the presence of blood in the sputum, a common sign of pulmonary edema. Excessive somnolence (A) is more indicative of respiratory depression or hypoxia, while epistaxis (B) is associated with hypertension or nasal trauma. Tachypnea (E) can be a sign of respiratory distress but does not specifically indicate pulmonary edema.
You may also like to solve these questions
A nurse is analyzing the ABG results of a client who is in respiratory acidosis. Which of the following mechanisms should the nurse identify as responsible for this acid-base imbalance?
- A. Retention of carbon dioxide
- B. Loss of bicarbonate
- C. Excessive vomiting
- D. Hyperventilation
Correct Answer: A
Rationale: The correct answer is A: Retention of carbon dioxide. In respiratory acidosis, there is an accumulation of carbon dioxide in the bloodstream due to inadequate ventilation. This leads to increased levels of carbonic acid, causing the blood pH to decrease. The nurse should identify this mechanism as responsible for the acid-base imbalance.
Loss of bicarbonate (B) would lead to metabolic acidosis, not respiratory acidosis. Excessive vomiting (C) would result in metabolic alkalosis. Hyperventilation (D) would actually help correct respiratory acidosis by blowing off excess carbon dioxide.
A nurse is caring for a client who has a small bowel obstruction and an NG tube in place. Which of the following actions should the nurse take?
- A. Maintain low intermittent suction.
- B. Clamp the NG tube every 2 hours.
- C. Remove the NG tube immediately.
- D. Encourage high-fiber foods.
Correct Answer: A
Rationale: The correct answer is A: Maintain low intermittent suction. This is because in a small bowel obstruction, the NG tube helps decompress the bowel by removing gastric contents and relieving pressure. Low intermittent suction helps prevent excessive suction which can cause tissue damage.
Clamping the NG tube every 2 hours (choice B) is incorrect as it will prevent the tube from effectively decompressing the bowel. Removing the NG tube immediately (choice C) is also incorrect as it is needed for decompression. Encouraging high-fiber foods (choice D) is contraindicated as they can worsen the obstruction.
A nurse is preparing to administer potassium chloride 10 mEq IV over 1 hr to a client. Available is potassium chloride 10 mEq in 100 mL of 0.9% sodium chloride. The nurse should set the infusion pump to deliver how many mL/hr? (Round to the nearest whole number.)
- A. 50 mL/hr
- B. 75 mL/hr
- C. 100 mL/hr
- D. 125 mL/hr
Correct Answer: C
Rationale: To determine the infusion rate, we first calculate the total volume of the solution to be infused (100 mL) over the total time (1 hr). Therefore, the infusion pump should be set to deliver 100 mL/hr (Choice C). This ensures the correct administration of potassium chloride 10 mEq IV over 1 hr. Choices A, B, and D are incorrect because they do not accurately reflect the infusion rate required for the specified dose and time frame.
A nurse is reviewing the medical record of a client who has acute gout. The nurse should expect an increase in which of the following laboratory results?
- A. Intrinsic factor
- B. Uric acid
- C. Chloride level
- D. Creatinine kinase
Correct Answer: B
Rationale: The correct answer is B: Uric acid. In acute gout, there is an accumulation of uric acid crystals in the joints, leading to inflammation and pain. As a result, the uric acid levels in the blood increase. Monitoring uric acid levels helps in diagnosing and managing gout.
Explanation for other choices:
A: Intrinsic factor - Intrinsic factor is related to vitamin B12 absorption, not gout.
C: Chloride level - Chloride level is not directly impacted by acute gout.
D: Creatinine kinase - Creatinine kinase is an enzyme related to muscle breakdown, not specifically affected by gout.
A nurse is preparing to administer propranolol to several clients. For which of the following clients should the nurse clarify the prescription with the provider before administration?
- A. A client who has a history of asthma
- B. A client who has hypertension
- C. A client who has a history of migraines
- D. A client who has stable angina
Correct Answer: A
Rationale: The correct answer is A. Propranolol is a non-selective beta-blocker that can potentially worsen asthma symptoms by causing bronchoconstriction. Therefore, for a client with a history of asthma, the nurse should clarify the prescription with the provider to avoid exacerbating respiratory issues. The other choices (B, C, D) do not typically contraindicate propranolol administration, as it is commonly used to manage hypertension, migraines, and stable angina. It is important to consider individual client factors when administering medications to ensure safety and effectiveness.