Nokea
The client in the intensive care department is receiving 2 mcg/kg/min of dopamine, an inotropic vasopressor. Which intervention should the nurse include in the plan of care?
- A. Monitor the client's blood pressure every two (2) hours.
- B. Assess the client's peripheral pulses every shift.
- C. Use a urometer to assess hourly output.
- D. Ensure the IV tubing is not exposed to the light.
Correct Answer: C
Rationale: Dopamine affects renal perfusion; hourly urine output via urometer monitors efficacy and prevents toxicity. BP, pulses, or light exposure are less critical.
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An adult is hospitalized for an acute attack of gout. Which medication should the nurse expect to administer?
- A. Morphine
- B. Colchicine
- C. Allopurinol
- D. Acetaminophen
Correct Answer: B
Rationale: Colchicine is used to treat acute gout attacks by reducing inflammation, unlike allopurinol, which prevents attacks.
The client with coronary artery disease is prescribed one (1) baby aspirin a day. Which instructions should the nurse provide the client concerning this medication?
- A. Take the medication on an empty stomach.
- B. Do not take Tylenol while taking this drug.
- C. If experiencing joint pain, notify the HCP.
- D. Notify the HCP if stools become dark and tarry.
Correct Answer: D
Rationale: Dark, tarry stools suggest GI bleeding, a serious aspirin side effect, requiring HCP notification. Empty stomach, Tylenol, or joint pain are less critical.
A client newly diagnosed with Type I Diabetes Mellitus asks the purpose of the test measuring glycosylated hemoglobin. The nurse should explain that the purpose of this test is to determine:
- A. The presence of anemia often associated with Diabetes
- B. The oxygen carrying capacity of the client's red cells
- C. The average blood glucose for the past 2-3 months
- D. The client's risk for cardiac complications
Correct Answer: C
Rationale: The average blood glucose for the past 2-3 months. By testing the portion of the hemoglobin that absorbs glucose, it is possible to determine the average blood glucose over the life span of the red cell, 120 days.
A client with atrial fibrillation is receiving digoxin (Lanoxin). Which of these assessments is most important for the nurse to perform?
- A. Monitor blood pressure every 4 hours
- B. Measure apical pulse prior to administration
- C. Maintain accurate intake and output records
- D. Record an EKG strip after administration
Correct Answer: B
Rationale: Measure apical pulse prior to administration. Digitoxin decreases conduction velocity through the AV node and prolongs the refractory period. If the apical heart rate is less than 60 beats/minute, withhold the drug. The apical pulse should be taken with a stethoscope so that there will be no mistake about what the heart rate actually is.
The client's vital signs are T 99.2°F, AP 59, R 20, and BP 108/72. Which medication would the nurse question administering?
- A. Theo-Dur, a bronchodilator.
- B. Inderal, a beta blocker.
- C. Ampicillin, an antibiotic.
- D. Cardizem, a calcium channel blocker.
Correct Answer: B
Rationale: Inderal (propranolol) slows HR; an apical pulse of 59 warrants holding it, per guidelines, to avoid bradycardia. Other meds are unaffected by HR.