Nokea
A nurse is assisting with the care of a postoperative client who has developed malignant hyperthermia. Which of the following actions should the nurse take?
- A. Administer meperidine IM.
- B. Instill a warm enema solution.
- C. Apply a cooling blanket.
- D. Ventilate client with 50% oxygen.
Correct Answer: C
Rationale: A cooling blanket lowers body temperature in malignant hyperthermia, a life-threatening condition. Meperidine, warm enemas, and oxygen alone don't address the hyperthermia directly.
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A nurse is reviewing the laboratory data of a client who is scheduled for a liver biopsy. Which of the following values should the nurse report to the provider?
- A. Bilirubin 1.0 mg/dL (0.3 to 1.0 mg/dL)
- B. Aspartate aminotransferase 34 units/L (0 to 34 units/L)
- C. Ammonia 55 mcg/dL (10 to 80 mcg/dL)
- D. Platelets 60,000/mm3 (150,000 to 400,000/mm3)
Correct Answer: D
Rationale: A platelet count of 60,000/mm3 is significantly below the normal range and increases the risk of bleeding during a liver biopsy, so it should be reported. The other values are within normal limits and do not pose an immediate concern.
A nurse is obtaining a sterile urine specimen from a client who has an indwelling urinary catheter. Identify the sequence the nurse should follow.
- A. Empty the urine into a sterile container labeled with the client identifiers.
- B. Document in the client's electronic medical record that the specimen was sent to the laboratory.
- C. Attach a sterile needleless syringe to the sample port and aspirate the specimen.
- D. Wipe the sample port with an alcohol wipe and let the alcohol dry.
- E. Clamp the catheter tubing distal to the sampling port for 15 min.
Correct Answer: E,D,C,A,B
Rationale: Order: Clamp (E), wipe port (D), aspirate (C), transfer (A), document (B) ensures sterility and proper procedure.
Exhibit 1 Exhibit 2 Exhibit 3 Exhibit 4
Medical History
Today, 0700:
Admitting Diagnosis: Heart Failure
Past medical history of heart failure, coronary artery disease, sleep apnea
Client reports diarrhea, dry mouth, and unusual thirst for the past three days
A nurse is assisting in the care of a male client who has a new prescription for furosemide. Which of the following client findings should the nurse identify as a contraindication to the administration of furosemide?
- A. Potassium level
- B. Blood pressure
- C. Prescription for digoxin
- D. Client verbal report
- E. BUN
Correct Answer: A
Rationale: Furosemide, a loop diuretic, treats heart failure but depletes potassium, risking hypokalemia. A low potassium level (e.g., <3.5 mEq/L) contraindicates its use hypokalemia causes arrhythmias, especially with heart failure's cardiac strain, per pharmacology standards. Blood pressure matters hypotension may worsen with diuresis but isn't a direct contraindication unless extreme. Digoxin use heightens hypokalemia risk (enhancing toxicity), but potassium level drives the decision. The client's report of diarrhea and thirst suggests dehydration, a caution, not a strict contraindication. Low potassium demands correction (e.g., supplements) before furosemide, preventing lethal complications like ventricular fibrillation, making it the critical finding to identify.
A nurse is contributing to the plan of care for a client who has developed an infectious wound with foul-smelling drainage. Which of the following actions should the nurse include in the plan of care?
- A. Discard soiled wound care supplies in a trash receptacle outside the client's room.
- B. Administer antibiotic therapy before culturing the client's wound.
- C. Place the client in a private room with a private bathroom.
- D. Instruct visitors to perform hand hygiene for 5 seconds after leaving the client's room.
Correct Answer: C
Rationale: A private room with a private bathroom helps control infection spread from a foul-smelling, infectious wound. Supplies should be discarded in biohazard containers, cultures taken before antibiotics, and hand hygiene should be thorough, not just 5 seconds.
A nurse is evaluating a client's acceptance of having a new ileostomy. Which of the following statements by the client indicates acceptance?
- A. I wish my sexual relationship with my partner was like it was before.
- B. I have my partner empty the bag for me, so I don't have to look at it
- C. I look forward to having normal bowel movements again.
- D. I will attend a support group to help me handle difficulties when they occur.
Correct Answer: D
Rationale: Attending a support group shows proactive acceptance and coping with the ileostomy. Other statements reflect denial or avoidance of the new reality.