Nokea
A nurse is caring for a client who develops a pulmonary embolism. Which of the following interventions should the nurse implement first?
- A. Administer oxygen therapy
- B. Start an IV infusion of Lactated Ringer's
- C. Initiate cardiac monitoring
- D. Give morphine IV
Correct Answer: A
Rationale: Oxygen is first priority to address hypoxemia caused by PE.
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The nurse is monitoring a client who just finished a meal for vasomotor manifestations of dumping syndrome. Which of the following findings indicate this occurrence?
- A. Dizziness and pallor
- B. Abdominal cramping and pain
- C. Bradycardia and indigestion
- D. Double vision and chest pain
Correct Answer: A
Rationale: Vasomotor symptoms (dizziness, pallor, diaphoresis) occur from rapid fluid shifts in dumping syndrome.
A nurse is reviewing the laboratory data of a client following a hemodialysis treatment. The nurse should expect to find a decrease in which of the following laboratory values?
- A. RBC count
- B. Protein
- C. Potassium
- D. Calcium
Correct Answer: C
Rationale: Potassium levels decrease after hemodialysis as it is effectively removed during the treatment.
A nurse is teaching a client about self-administering peritoneal dialysis. Which of the following statements by the client indicates a need for further teaching?
- A. The microwave in my kitchen can warm the solution before I use it.
- B. The catheter can become infected even with sterile precautions.
- C. The volume of the output solution should be greater than the input solution.
- D. The fluid from my abdomen will be clear or slightly yellow.
Correct Answer: A
Rationale: Microwaving can unevenly heat solution and is not recommended; solutions should be warmed using approved methods.
The client is scheduled to receive 30 grams of lactulose orally every 12 hours. An oral solution containing 5 g/10 mL is available. How many mL should be poured into the medication cup to administer the required dose?
Correct Answer: 60
Rationale: Calculation: (30 g ÷ 5 g) × 10 mL = 60 mL
A nurse is teaching an ACLS class and is discussing heart rhythms and treatment. Which of the following rhythms would indicate the need for defibrillation?
- A. Atrial fibrillation
- B. Supraventricular tachycardia
- C. Asystole
- D. Ventricular fibrillation
Correct Answer: D
Rationale: Ventricular fibrillation is a life-threatening rhythm requiring immediate defibrillation.