Nokea
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.
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A student nurse asks the RN about the clinical manifestations of a thoracic aortic aneurysm. Which of the following findings should the nurse discuss? (Select all that apply).
- A. Shortness of breath
- B. Difficulty swallowing
- C. Upper chest pain
- D. Diaphoresis
- E. Cough
- F. Hoarseness
Correct Answer: A,B,C,E,F
Rationale: These reflect compression of adjacent structures (trachea, esophagus, recurrent laryngeal nerve) by the aneurysm.
A client who has a recent closed head injury reports a severe headache and is restless. Which of the following is an appropriate nursing intervention?
- A. Place a cool cloth on the forehead.
- B. Elevate the head of the bed 30 degrees.
- C. Administer morphine 2 mg IV.
- D. Prepare for a lumbar puncture.
Correct Answer: B
Rationale: Elevating the HOB decreases intracranial pressure which may be causing the headache.
A nurse is preparing to administer digoxin at a dosage of 8 mcg/kg/day orally, divided equally every 12 hours, to a preschooler who weighs 33 lbs. Digoxin elixir is available at a concentration of 0.05 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: 1.2
Rationale: Calculation: 33 lbs ÷ 2.2 = 15 kg; 15 kg × 8 mcg/kg/day = 120 mcg/day; 120 mcg ÷ 2 = 60 mcg/dose; 60 mcg = 0.06 mg; 0.06 mg ÷ 0.05 mg/mL = 1.2 mL
A client arrives at the emergency room with symptoms of peptic ulcer disease. Which of these symptoms should the nurse identify as the priority?
- A. Hematemesis
- B. Abdominal bloating
- C. Epigastric discomfort
- D. Dyspepsia
Correct Answer: A
Rationale: Hematemesis indicates active bleeding and is the most urgent concern.
A nurse is teaching a client who has acute kidney injury (AKI) about the oliguric phase. Which of the following information should the nurse include in the teaching?
- A. The glomerular filtration rate (GFR) recovers.
- B. Urine output is less than 400 mL per 24 hours.
- C. BUN and creatinine levels decrease.
- D. Renal function is reestablished.
Correct Answer: B
Rationale: Oliguria (<400mL/24hr) defines this phase of AKI with impaired urine production.