Nokea
Lithium carbonate is prescribed for an adult. The nurse knows the client is most likely to have which condition?
- A. Depression
- B. Mania
- C. Schizophrenia
- D. Paranoia
Correct Answer: B
Rationale: Lithium carbonate is primarily used to stabilize mood in bipolar disorder, particularly for mania.
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The nurse is caring for a client who is receiving IV gentamicin for a gram-negative infection. Which of the following laboratory results would be of GREATest concern to the nurse?
- A. Creatinine 2.5 mg/dL.
- B. Sodium 140 mEq/L.
- C. Potassium 4.0 mEq/L.
- D. Hemoglobin 13 g/dL.
Correct Answer: A
Rationale: A creatinine of 2.5 mg/dL indicates renal impairment, a serious complication of gentamicin due to nephrotoxicity, requiring immediate evaluation. Options B, C, and D are normal: sodium 140 mEq/L, potassium 4.0 mEq/L, and hemoglobin 13 g/dL do not indicate complications.
The nurse is admitting a client to the unit from the postoperative recovery area after abdominal exploratory surgery.
After determining the client's vital signs, which of the following activities should the nurse perform next?
- A. Position the client on her left side, supported with pillows.
- B. Check the chart and determine the status of the fluid balance from surgery.
- C. Check the client's abdominal dressing for any evidence of bleeding.
- D. Monitor the incision and pulmonary status for the presence of infection.
Correct Answer: C
Rationale: Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? Yes. (1) implementation, complete assessment first (2) assessment, determine what is happening to the patient now (3) correct-assessment, dressing should be checked on admission to the room and frequently for the next several hours (4) inappropriate assessment, it is too soon for infection to occur secondary to surgery
The nurse is caring for a woman who is receiving internal radiation for cancer of the cervix. Which nursing action will do most to reduce the risk of radiation exposure to other clients?
- A. Keep the door to the client's room closed.
- B. Place the client in the bed closest to the outside window.
- C. Place the client in a room close to the nurse's station for continuous observation.
- D. Place a 'Do not enter' sign on the door to the client's room.
Correct Answer: A
Rationale: Keeping the door closed minimizes radiation exposure to others by containing emissions. Bed placement or signs are less effective, and observation doesn't reduce exposure.
A client is being followed in the rape-crisis clinic one week after being assaulted. The client is currently taking Xanax 0.25 mg PO q6h for anxiety. Which of the following statements, if made by the client to the nurse, reflects a correct understanding of this medication?
- A. I can take it whenever I feel upset.
- B. I should not take this with anything but water.
- C. I guess I need to stop drinking white wine.
- D. This medication will help me forget and go on.
Correct Answer: C
Rationale: Alcohol, including white wine, potentiates Xanax’s sedative effects, increasing risks. Avoiding it shows understanding. Options A, B, and D are incorrect.
The nurse is caring for an adult who has myasthenia gravis and is prescribed neostigmine. Which drug should the nurse plan to have readily available because the client is taking neostigmine?
- A. Atropine
- B. Vitamin K
- C. Protamine sulfate
- D. Calcium gluconate
Correct Answer: A
Rationale: Neostigmine, a cholinesterase inhibitor, can cause cholinergic crisis; atropine, an anticholinergic, is the antidote to reverse excessive muscarinic effects.