Nokea
A nurse is planning care for a client who has undergone cardiac catheterization through the femoral artery. Which of the following actions should the nurse plan to take?
- A. Instruct the client to perform range-of-motion exercises to his lower extremities.
- B. Ambulate the client 1 hour following the procedure.
- C. Restrict the client's fluid intake.
- D. Assess the color, temperature, and pulse in the affected extremity.
Correct Answer: D
Rationale: Assessing the extremity monitors for vascular complications like bleeding or occlusion post-catheterization.
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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.
The healthcare provider prescribes lactulose for a patient with hepatic encephalopathy. What will the nurse assess to determine the effectiveness of this medication?
- A. Decreased ammonia levels
- B. Relief of constipation
- C. Decreased liver enzymes
- D. Relief of abdominal pain
Correct Answer: A
Rationale: Lactulose works by reducing blood ammonia levels, which is its primary mechanism in treating hepatic encephalopathy.
The nurse would be most concerned about a prescription for a lipid emulsion for a client with which condition?
- A. Fractured femur
- B. Severe anorexia nervosa
- C. Gastrointestinal obstruction
- D. Chronic diarrhea and vomiting
Correct Answer: C
Rationale: Gastrointestinal obstruction contraindicates lipid emulsion administration as it could worsen the obstruction.
A client is receiving continuous enteral nutrition through a nasogastric small-bore silicone feeding tube. What should the nurse plan for when this client has a computed tomography (CT) scan ordered?
- A. Ask the healthcare provider to re-schedule the scan
- B. Send a suction catheter with the client in case of aspiration during the scan
- C. Shut the feeding off 30-60 minutes before the scan
- D. Connect the feeding tube to continuous suction before and during the exam
Correct Answer: C
Rationale: Stopping feeding 30-60 minutes before the scan reduces aspiration risk and prevents stomach contents from interfering with imaging.
A nurse admits a client to the emergency department who reports nausea, vomiting, and epigastric pain that worsens when lying down. The provider suspects acute pancreatitis. Which of the following laboratory test results should the nurse expect to see?
- A. Increased serum amylase
- B. Decreased WBC count
- C. Increased serum calcium
- D. Decreased serum lipase
Correct Answer: A
Rationale: Serum amylase rises quickly in acute pancreatitis due to pancreatic inflammation.