Nokea
The client is scheduled to receive 30 grams of lactulose orally every 12 hours. An oral solution containing 5 g/10 mL is available. How many mL should be poured into the medication cup to administer the required dose?
Correct Answer: 60
Rationale: Calculation: (30 g ÷ 5 g) × 10 mL = 60 mL
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A student nurse asks the RN about the clinical manifestations of a thoracic aortic aneurysm. Which of the following findings should the nurse discuss? (Select all that apply).
- A. Shortness of breath
- B. Difficulty swallowing
- C. Upper chest pain
- D. Diaphoresis
- E. Cough
- F. Hoarseness
Correct Answer: A,B,C,E,F
Rationale: These reflect compression of adjacent structures (trachea, esophagus, recurrent laryngeal nerve) by the aneurysm.
A client with advanced cirrhosis has been admitted to the medical-surgical unit. The nurse is assessing the client and identifies which of the following findings as indicators of hepatic encephalopathy? (Select all that apply).
- A. Asterixis
- B. Change in orientation
- C. Anorexia
- D. Ascites
- E. Fetor hepaticus
Correct Answer: A,B,E
Rationale: These are signs of hepatic encephalopathy reflecting cerebral effects of ammonia toxicity.
A nurse is reviewing the laboratory values of a client who had a myocardial infarction 3 hours ago. The nurse should expect which of the following laboratory values to be elevated?
- A. Troponin
- B. Aspartate aminotransferase (AST)
- C. Serum amylase
- D. Unconjugated bilirubin
Correct Answer: A
Rationale: Troponin rises within 3-12 hours post-MI and is the most specific marker for myocardial injury.
A client is admitted to the hospital with suspected rheumatic endocarditis. Which of the following laboratory tests would assist in confirming the diagnosis?
- A. Liver enzymes
- B. Serum albumin
- C. Throat culture
- D. Arterial blood gases
Correct Answer: C
Rationale: Throat culture can identify streptococcal infection preceding rheumatic fever/endocarditis.
A nurse is caring for a client who has a chest tube in place connected to a closed chest drainage system. Which of the following findings should indicate to the nurse that the client's lung has re-expanded?
- A. Occasional bubbling in the water-seal chamber
- B. No reports of pleuritic chest pain
- C. No tidaling in the water-seal chamber
- D. Oxygen saturation of 95%
Correct Answer: C
Rationale: Absence of tidaling indicates lung re-expansion as intrapleural pressure equalizes.