Nokea
The client with chronic alcoholism has chronic pancreatitis and hypomagnesemia. What should the nurse assess when administering magnesium sulfate to the client?
- A. Deep tendon reflexes
- B. Arterial blood gases
- C. Skin turgor
- D. Capillary refill time
Correct Answer: A
Rationale: Corrected Rationale: When administering magnesium sulfate to a client with chronic alcoholism, chronic pancreatitis, and hypomagnesemia, the nurse should assess deep tendon reflexes. Magnesium sulfate can depress the central nervous system and decrease deep tendon reflexes, so monitoring them is crucial. Assessing arterial blood gases, skin turgor, or capillary refill time is not directly related to the administration of magnesium sulfate in this scenario.
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When is Aspirin most effective when taken?
- A. On an empty stomach with cold water
- B. On a full stomach after a meal
- C. With a glass of fruit juice
- D. First thing in the morning
Correct Answer: A
Rationale: Aspirin is best absorbed on an empty stomach to maximize its effectiveness. Taking it with cold water helps to enhance absorption. Choice B is incorrect as taking aspirin on a full stomach may reduce its absorption. Choice C is incorrect as fruit juice can sometimes interact with medications. Choice D is incorrect as taking aspirin first thing in the morning may not optimize its absorption.
The nurse is told in report that the client has aortic stenosis. Which anatomical position should the nurse auscultate to assess the murmur?
- A. Second intercostal space, right sternal border
- B. Erb's point
- C. Second intercostal space, left sternal border
- D. Fourth intercostal space, left sternal border
Correct Answer: A
Rationale: The correct anatomical position for auscultating the murmur of aortic stenosis is the second intercostal space, right sternal border. This is where the aortic valve is best auscultated, and the murmur of aortic stenosis is heard most clearly. Choices B, C, and D are incorrect as the murmur of aortic stenosis is best heard at the second intercostal space on the right side of the sternum.
A 31-year-old client is seeking contraceptive information. Before responding to the client's questions about contraceptives, the nurse obtains a health history. What factor in the client's history indicates to the nurse that oral contraceptives are contraindicated?
- A. More than 30 years of age
- B. Had two multiple pregnancies
- C. Smokes 1 pack of cigarettes a day
- D. Has a history of borderline hypertension
Correct Answer: C
Rationale: The correct answer is C. Smoking, especially in clients over 30, increases the risk of thromboembolic events, making oral contraceptives contraindicated. Choice A is incorrect as age alone is not a contraindication for oral contraceptives. Choice B is incorrect as having multiple pregnancies is not a contraindication for oral contraceptives. Choice D is incorrect as borderline hypertension is not a strict contraindication for oral contraceptives.
A patient with chronic renal failure should avoid which of the following?
- A. Potassium
- B. Calcium
- C. Iron
- D. Zinc
Correct Answer: A
Rationale: Patients with chronic renal failure should avoid potassium due to impaired kidney function. The kidneys play a crucial role in regulating potassium levels in the body. In renal failure, the kidneys may not be able to excrete excess potassium effectively, leading to hyperkalemia. Calcium, iron, and zinc are not typically restricted in chronic renal failure unless there are specific individual circumstances, making them incorrect choices.
What signs/symptoms would the nurse expect to find in the client diagnosed with an insulinoma?
- A. Nervousness, jitteriness, and diaphoresis
- B. Flushed skin, dry mouth, and tented skin turgor
- C. Polyuria, polydipsia, polyphagia
- D. Hypertension, tachycardia, and feeling hot
Correct Answer: A
Rationale: The correct answer is A: 'Nervousness, jitteriness, and diaphoresis.' Insulinomas cause hypoglycemia due to excessive insulin production, leading to symptoms such as nervousness (from the sympathetic response to hypoglycemia), jitteriness, and diaphoresis (sweating). Choices B, C, and D are incorrect. Flushed skin, dry mouth, and tented skin turgor (Choice B) are not typical signs of insulinoma. Polyuria, polydipsia, and polyphagia (Choice C) are classic symptoms of diabetes mellitus, not insulinoma. Hypertension, tachycardia, and feeling hot (Choice D) are more indicative of hyperthyroidism or a hypermetabolic state, rather than an insulinoma presentation.