Nokea
A nurse is preparing to administer furosemide intravenously to a client. Which action should the nurse perform before administering this medication?
- A. Insert an indwelling urinary catheter.
- B. Review the client's most recent pulse
- C. Establish continuous pulse oximeter monitoring
- D. Assess the client's serum electrolytes
Correct Answer: D
Rationale: Furosemide can cause electrolyte imbalances, so assessing serum electrolytes is critical before administration.
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The nurse is reviewing a care plan for a client with chronic pain receiving morphine sulfate. Which of the following aspects in the plan of care require revision?
- A. Adjust the physician's order based on the client's pain level
- B. Ensure naloxone is always available
- C. Check the client's blood pressure before administering morphine sulfate
- D. Provide a high-fiber diet
Correct Answer: A
Rationale: Nurses cannot adjust physician orders independently; this requires clarification or a new order from the provider.
The nurse in the emergency department (ED) is caring for a 62-year-old male client.
Item 3 of 6
Triage Note
1700:
• The client was brought to the ED after collapsing on a tennis court.
• Vital signs: BP 94/57, T 105° F (40.5° C), P 115, RR 26, Pulse oximetry 95% on room air. • The client is lethargic and confused. Skin is pale, and there is some perspiration on the forehead. Thready peripheral pulses, clear lung fields bilaterally, tachypnea, shallow respirations.
The client is at highest risk for developing ……………..
- A. stroke.
- B. multiple organ dysfunction.
- C. a myocardial infarction.
- D. respiratory acidosis.
Correct Answer: B
Rationale: The client's severe hyperthermia, hypotension, tachycardia, and confusion suggest heat stroke, which can lead to multiple organ dysfunction due to systemic inflammation and hypoperfusion. Stroke (A), myocardial infarction (C), and respiratory acidosis (D) are less directly associated with heat stroke complications.
A 60-year-old female with chronic cancer pain has been receiving opiates for 4 months. She rated her pain as an 8 on a 10-point scale before starting the opioid medication. She has just had a thorough examination with no new evidence of increased disease, yet her pain is close to 8 again. The most likely explanation for her increasing pain is:
- A. Development of an addiction to the opioids.
- B. Tolerance to the opioid.
- C. Withdrawal from the opioid.
- D. Placebo effect has decreased.
Correct Answer: B
Rationale: Tolerance to opioids is the most likely explanation, as the body adapts to the medication over time, reducing its effectiveness and requiring a dose adjustment.
In preparation for total knee surgery, a 200-lb client with osteoarthritis must lose weight. Which of the following exercises should the nurse recommend as best if the client has no contraindications?
- A. Weight lifting.
- B. Walking.
- C. Aquatic exercise.
- D. Tai chi exercise.
Correct Answer: C
Rationale: Aquatic exercise reduces joint stress while promoting weight loss, ideal for osteoarthritis.
A 79-year-old female client is admitted to the hospital with a diagnosis of bacterial pneumonia. While obtaining the client's health history, the nurse learns that the client has osteoarthritis, follows a vegetarian diet, and is very concerned with cleanliness. Which of the following would most like to a predisposing factor for the diagnosis of pneumonia?
- A. Age.
- B. Osteoarthritis.
- C. Vegetarian diet.
- D. Daily bathing.
Correct Answer: A
Rationale: Advanced age weakens the immune system and respiratory muscles, increasing pneumonia risk. Osteoarthritis, a vegetarian diet, and daily bathing do not directly predispose to pneumonia.