Nokea
Review H and P, nurse's notes, laboratory values, flow sheet, and prescriptions.Click to mark whether the assessment finding represents a therapeutic result of the mannitol administered, a non-therapeutic side effect, or an unrelated finding. Each row must have one option selected.
- A. Peripheral edema: Non-therapeutic side effect
- B. Potassium 2.9: Non-therapeutic side effect
- C. Urine output 280 ml: Therapeutic result
- D. Heart rate 79: Unrelated finding
- E. Intracranial pressure 11mmHg: Therapeutic result
- F. Oxygen saturation: Unrelated finding
Correct Answer:
Rationale: A: Edema is a mannitol side effect. B: Hypokalemia is a side effect. C: Increased urine output is therapeutic. D: Normal heart rate is unrelated. E: Reduced intracranial pressure is therapeutic. F: Normal oxygen saturation is unrelated.
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A client with a history of anaphylactic reaction to penicillin receives a prescription for cephalexin 500 mg PO twice daily. Which action should the nurse take?
- A. Administer the medication as prescribed.
- B. Monitor the client for a rash or hives.
- C. Contact the healthcare provider.
- D. Give with prescribed antihistamine.
Correct Answer: B
Rationale: Cephalexin may cause cross-reactivity in penicillin-allergic clients, so monitoring for allergic reactions like rash or hives is critical. Administering without monitoring, contacting the provider immediately, or giving antihistamines prophylactically are less appropriate.
A client is scheduled for a spiral computed tomography (CT) scan with contrast to evaluate for pulmonary embolism. Which information in the client's history requires follow-up by the nurse?
- A. Metal hip prosthesis was placed twenty years ago.
- B. Takes metformin hydrochloride for type 2 diabetes mellitus.
- C. Report of client's sobriety for the last five years.
- D. CT scan that was performed six months earlier.
Correct Answer: B
Rationale: Metformin use requires follow-up due to the risk of lactic acidosis with contrast agents affecting renal function. Metal prostheses, sobriety, and prior CT scans are less relevant to contrast administration safety.
A client with narcolepsy receives a new prescription for methylphenidate. Prior to administration of the medication, the nurse should review the medical record for which condition?
- A. Hypercholesterolemia.
- B. Bronchitis.
- C. Diabetes mellitus.
- D. Hypertension.
Correct Answer: D
Rationale: Methylphenidate, a stimulant, can exacerbate hypertension, requiring careful review of blood pressure history. Hypercholesterolemia, bronchitis, and diabetes are less critical concerns.
When preparing to apply a scheduled fentanyl transdermal patch, the nurse notes that the previously applied patch is intact on the client's upper back and the client denies pain. Which action should the nurse take?
- A. Administer an oral analgesic and evaluate its effectiveness before applying the new patch.
- B. Apply the new patch in a different location after removing the original patch.
- C. Place the patch on the client's shoulder and leave both patches in place for 12 hours.
- D. Remove the patch and consult with the healthcare provider about the client's pain resolution.
Correct Answer: B
Rationale: Fentanyl transdermal patches should be applied to a different location after removing the original patch to ensure consistent pain management while preventing skin irritation or overdose. Administering an oral analgesic is unnecessary if the client has no pain, leaving both patches risks overdose, and consulting the provider is not immediate unless opioid need is reassessed.
A male client who has been taking a high dose of a nonsteroidal antiinflammatory drug (NSAID) comes to the clinic reporting gastric pain and blood in his stool. The healthcare provider discontinues the NSAIDs and prescribes esomeprazole. Which information should the nurse include in this client's teaching plan?
- A. Once pain subsides, NSAID therapy can be resumed.
- B. Resume a diet that consists of milk, cream, and bland foods.
- C. Notify the healthcare provider of the passage of black stools.
- D. Call the clinic if diarrhea or headache occur when taking esomeprazole.
Correct Answer: C
Rationale: Black stools indicate potential gastrointestinal bleeding, a serious NSAID complication, requiring immediate provider notification. Resuming NSAIDs risks further damage, bland diets are outdated, and diarrhea/headache are less urgent.