Nokea
A nurse is caring for a client who has a spinal cord injury and suspects the client is developing autonomic dysreflexia. Which of the following actions should the nurse take first?
- A. Place the client in a sitting position
- B. Examine the client for areas of skin breakdown
- C. Check the client's bladder for distention
- D. Check the client for a fecal impaction
Correct Answer: A
Rationale: Sitting position lowers BP immediately by promoting venous pooling, addressing the hypertensive crisis.
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A nurse is preparing to administer a 2 mg IV bolus of morphine sulfate. Morphine sulfate is available in a concentration of 10 mg/mL. How many mL 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: 0.2
Rationale: Calculation: 2 mg ÷ 10 mg/mL = 0.2 mL
A nurse is caring for a client who has just developed a pulmonary embolism. Which of the following medications should the nurse anticipate administering?
- A. Atropine
- B. Furosemide
- C. Heparin
- D. Dexamethasone
Correct Answer: C
Rationale: Heparin is an anticoagulant used in the initial treatment of pulmonary embolism to prevent further clot formation.
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 caring for a client who has acute respiratory failure (ARF). The nurse should monitor the client for which of the following manifestations of this condition? (Select all that apply).
- A. Hypoxemia
- B. Confusion
- C. Dyspnea
- D. Bradycardia
- E. Hypocarbia
Correct Answer: A,B,C,E
Rationale: These are common manifestations of ARF reflecting impaired gas exchange and cerebral effects of abnormal blood gases.
A client in the emergency department has suspected stomach perforation due to a peptic ulcer. The nurse is completing the assessment and should expect which of the following findings? (Select all that apply).
- A. Tachycardia
- B. Rebound tenderness
- C. Rigid abdomen
- D. Elevated blood pressure
Correct Answer: A,B,C
Rationale: These are classic signs of perforation and peritonitis: tachycardia from pain/stress, rebound tenderness and rigidity from peritoneal irritation.