Nokea
Captopril (Capoten), furosemide (Lasix), and metoprolol (Toprol XL) are ordered for a client with systolic heart failure. The client's blood pressure is 136/82 and the heart rate is 65. Prior to medication administration at 9 a.m., the nurse reviews the following lab tests (see chart). Which of the following should the nurse do first?
- A. Administer the medications.
- B. Call the physician.
- C. Withhold the captopril.
- D. Question the metoprolol dose.
Correct Answer: B
Rationale: The potassium level of 6.8 mEq/L indicates hyperkalemia, a risk with captopril (an ACE inhibitor). Calling the physician is the priority to address this critical lab value.
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The nurse should teach the client with Addison's disease that the adverse effect of bronze-colored skin is thought to be caused by which of the following?
- A. Hypersensitivity to sun exposure.
- B. Increased serum bilirubin level.
- C. Adverse effects of the glucocorticoid therapy.
- D. Increased secretion of adrenocorticotropic hormone (ACTH).
Correct Answer: D
Rationale: Bronze-colored skin in Addison's disease results from increased ACTH, which stimulates melanin production.
The nurse is taking care of a client with a spinal cord injury. The extent of the client's injury is shown below. Which of the following findings is expected when assessing this client?
- A. Inability to move his arms.
- B. Loss of sensation in his hands and fingers.
- C. Incontinence of bowel and bladder.
- D. Spasticity of the lower extremities.
Correct Answer: C
Rationale: Incontinence is expected with spinal cord injuries due to disruption of neural control over bowel and bladder.
Which of the following should the nurse include when preparing a client for magnetic resonance imaging (MRI) to evaluate a ruptured disc?
- A. Informing the client that the procedure is painless.
- B. Taking a thorough history of past surgeries.
- C. Checking for previous complaints of claustrophobia.
- D. Starting an I.V. line at keep-open rate.
Correct Answer: C
Rationale: Checking for claustrophobia is essential, as MRI can be distressing for claustrophobic clients.
The client with an intestinal obstruction continues to have acute pain even though the nasoenteric tube is patent and draining. Which action by the nurse would be most appropriate?
- A. Reassure the client that the nasoenteric tube is functioning.
- B. Assess the client for a rigid abdomen.
- C. Administer an opioid as ordered.
- D. Reposition the client on the left side.
Correct Answer: B
Rationale: Persistent acute pain despite a patent nasoenteric tube suggests a complication like peritonitis, indicated by a rigid abdomen, which requires immediate assessment. Reassurance, opioids, or repositioning may delay addressing a serious issue. CN: Physiological adaptation; CL: Synthesize
Which of the following medications would be appropriate for the treatment of an allergic reaction to a blood transfusion? Select all that apply.
- A. Epinephrine
- B. Acetaminophen
- C. Diphenhydramine
- D. Hydrocortisone
- E. Pantoprazole
Correct Answer: A,C,D
Rationale: Epinephrine treats severe allergic reactions (anaphylaxis), diphenhydramine manages mild to moderate allergic symptoms, and hydrocortisone reduces inflammation in allergic reactions. Acetaminophen is for fever or pain, and pantoprazole is for gastric issues, not allergic reactions.