Nokea
Lab results indicate that the client's serum aminophylline level is 17 mcg/mL. The nurse recognizes that the aminophylline level is:
- A. Within therapeutic range
- B. Too high and should be reported
- C. Questionable and should be repeated
- D. Too low to be therapeutic
Correct Answer: A
Rationale: The therapeutic range for aminophylline is typically 10-20 mcg/mL. A level of 17 mcg/mL is within this range, so no action is needed. Answer B is incorrect as the level is not too high. Answer C is unnecessary as the level is clearly therapeutic. Answer D is incorrect as the level is not too low.
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At the geriatric day care program a client is crying and repeating 'I want to go home. Call my daddy to come for me.' The nurse should
- A. Inform the client that she must wait until the program ends at 5:00 pm to leave
- B. Give the client simple information about what she will be doing
- C. Tell the client you will call someone to come for her and suggest joining the exercise group while she waits
- D. Firmly direct the client to her assigned group activity
Correct Answer: C
Rationale: Tell the client you will call someone to come for her and suggest joining the exercise group while she waits. This uses comforting and distraction to reduce distress in dementia.
Divalproex sodium (Depakote) is prescribed for a 28-year-old female. Which lab test would the nurse expect prior to administration of the medication?
- A. Urine drug screen
- B. Pregnancy test
- C. CBC with differential
- D. Liver function tests
Correct Answer: B
Rationale: Divalproex is teratogenic; a pregnancy test is critical in females of childbearing age to prevent fetal harm.
Which of the following nursing assessment findings require immediate discontinuance of an antipsychotic medication?
- A. Involuntary rhythmic stereotypic movements and tongue protrusion
- B. Cheek puffing, involuntary movements of extremities and trunk
- C. Agitation, constant state of motion
- D. Hyperpyrexia, severe muscle rigidity, malignant hypertension
Correct Answer: D
Rationale: Hyperpyrexia, severe muscle rigidity, and malignant hypertension are signs of neuroleptic malignant syndrome (NMS), requiring immediate discontinuation of the antipsychotic.
Laboratory results
Hematocrit
Male: 42%-52%
(0.42-0.52)
Female: 37%-47%
(0.37-0.47) 29%
(0.29)
Hemoglobin
Male: 14-18 g/dL
(140-180 g/L)
Female: 12-16 g/dL
(120-160 g/L) 9.7 g/dL
97 (g/L)
The nurse is caring for a client with chronic kidney disease who is scheduled to receive recombinant human erythropoietin and iron sucrose. Which of the following actions should the nurse take?
- A. Administer erythropoietin in the client's ventrogluteal muscle.
- B. Check the client's blood pressure prior to administering erythropoietin.
- C. Contact the health care provider to clarify the prescription for iron sucrose.
- D. Hold erythropoietin and inform the health care provider of the laboratory test results.
Correct Answer: B
Rationale: Erythropoietin can increase blood pressure, so checking BP is essential. It's given IV or SC, not IM . Iron sucrose is standard , and holding erythropoietin requires lab evidence.
The school nurse monitors an 8-year-old with a history of asthma. The nurse notes mild wheezing and coughing. Which action should the nurse perform first?
- A. Call the health care provider
- B. Determine the client's peak expiratory flow
- C. Notify the client's parents
- D. Remind the client about avoiding triggers
Correct Answer: B
Rationale: Measuring peak expiratory flow assesses asthma severity first. Calling the provider , notifying parents , or discussing triggers follows based on the assessment.