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 nurse is preparing to administer intermittent lipid emulsion and notes a layer of fat floating in the IV solution bag. Which action should the nurse take?
- A. Shake the bag to mix the fat.
- B. Administer the bag of solution.
- C. Return the bag to the pharmacy.
- D. Turn the bag upside down one time.
Correct Answer: C
Rationale: Fat separation indicates instability; solution should be returned to pharmacy as it could cause fat embolism.
A nurse is caring for a client who has cirrhosis of the liver. Which of the following medications should the nurse anticipate may be ordered for this client? (Select all that apply.)
- A. Beta-blocking agent
- B. Diuretic
- C. Opioid analgesic
- D. Lactulose
- E. Sedative
Correct Answer: A,B,D
Rationale: Beta-blockers reduce portal pressure, diuretics manage ascites, and lactulose treats hepatic encephalopathy.
A nurse is assessing a client who has chronic kidney disease for fluid volume increase. Which of the following provides a reliable measure of fluid retention?
- A. Sodium level
- B. Intake and output
- C. Daily weight
- D. Tissue turgor
Correct Answer: C
Rationale: Daily weight is the most reliable measure of fluid retention as 1 kg weight gain equals approximately 1 liter fluid retention.
A client with advanced cirrhosis has been admitted to the medical-surgical unit. The nurse is assessing the client and identifies which of the following findings as indicators of hepatic encephalopathy? (Select all that apply).
- A. Asterixis
- B. Change in orientation
- C. Anorexia
- D. Ascites
- E. Fetor hepaticus
Correct Answer: A,B,E
Rationale: These are signs of hepatic encephalopathy reflecting cerebral effects of ammonia toxicity.
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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