Nokea
A nurse is teaching a group of nurses about the administration of nitroglycerin. Which of the following routes of administration provides the most rapid onset for the client?
- A. Topical ointment
- B. Sustained-release
- C. Sublingual
- D. Transdermal patch
Correct Answer: C
Rationale: Sublingual nitroglycerin has the fastest onset (1-3 minutes) due to direct absorption into bloodstream.
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A nurse is caring for a client during his first hemodialysis treatment. The client reports a headache, nausea, and is agitated. Which of the following complications should the nurse identify these findings as manifestations of?
- A. Disequilibrium syndrome
- B. Septicemia
- C. Air embolism
- D. Peritonitis
Correct Answer: A
Rationale: These are classic symptoms of disequilibrium syndrome from rapid fluid/electrolyte shifts during initial dialysis.
A nurse is assessing a client who has left-sided heart failure. Which of the following clinical manifestations will the nurse expect?
- A. Lower extremity edema
- B. Crackles in lung bases
- C. Jugular vein distention
- D. Ascites
Correct Answer: B
Rationale: Crackles indicate pulmonary congestion characteristic of left-sided heart failure.
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.
The healthcare provider has determined that a client has contracted hepatitis A based on flu-like symptoms and jaundice. Which statement made by the client supports this medical diagnosis?
- A. I was an intravenous drug abuser in the past and shared needles.
- B. I ate shellfish about 2 weeks ago at a local restaurant.
- C. I had a blood transfusion 30 years ago after major abdominal surgery.
- D. I have had unprotected sex with multiple partners.
Correct Answer: B
Rationale: Hepatitis A is typically transmitted through contaminated food/water - shellfish is a known source.
A nurse is caring for a client who has heart failure and a prescription for digoxin 125 mcg orally daily. Digoxin is available in 0.25 mg/tablet form. How many tablets 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: 0.5
Rationale: Calculation: 125 mcg = 0.125 mg; 0.125 mg ÷ 0.25 mg/tablet = 0.5 tablets