Nokea
The doctor has ordered 80 mg of furosemide (Lasix) two times per day. The nurse notes the patient's potassium level to be 2.5 meq/L. The nurse should:
- A. Administer the Lasix as ordered
- B. Administer half the dose
- C. Offer the patient a potassium-rich food
- D. Withhold the drug and call the doctor
Correct Answer: D
Rationale: A potassium level of 2.5 mEq/L is dangerously low; withholding Lasix and notifying the doctor prevents further potassium loss.
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The nurse is caring for a client with a head injury who has an intracranial pressure monitor in place. Assessment reveals an ICP reading of 66. What is the nurse's best action?
- A. Notify the physician
- B. Record the reading as the only action
- C. Turn the client and recheck the reading
- D. Place the client supine
Correct Answer: A
Rationale: An ICP of 66 mmHg is critically high (normal <20 mmHg), indicating severe brain swelling. Notifying the physician is urgent for immediate intervention.
The nurse is preparing to discharge a client following a laparoscopic cholecystectomy. The nurse should:
- A. Tell the client to avoid a tub bath for 48 hours
- B. Tell the client to expect clay-colored stools
- C. Tell the client that she can expect lower abdominal pain for the next week
- D. Tell the client to report pain in the back or shoulders
Correct Answer: D
Rationale: Pain in the back or shoulders post-laparoscopic cholecystectomy may indicate referred pain from residual CO2 or complications, requiring prompt reporting.
A client has just finished her lunch, consisting of shrimp with rice, fruit salad, and a roll. The client calls for the nurse, stating, 'My throat feels thick and I'm having trouble breathing.' What action should the nurse implement first?
- A. Place the bed in Trendelenburg position and call the physician
- B. Take the client's vital signs and administer Benadryl 50 mg PO
- C. Place the bed in high Fowler's position and call the physician
- D. Start an Aminophylline drip and call the physician
Correct Answer: C
Rationale: Symptoms suggest an allergic reaction, possibly anaphylaxis from shrimp. Placing the client in high Fowler's position facilitates breathing, and calling the physician ensures rapid intervention.
The physician has ordered a low-purine diet for a client with gout. Which protein source is high in purine?
- A. Dried beans
- B. Nuts
- C. Cheese
- D. Eggs
Correct Answer: A
Rationale: Dried beans are high in purines, which can increase uric acid levels and exacerbate gout symptoms.
The nurse is assessing the abdomen. The nurse knows the best sequence to perform the assessment is:
- A. Inspection, auscultation, palpation
- B. Auscultation, palpation, inspection
- C. Palpation, inspection, auscultation
- D. Inspection, palpation, auscultation
Correct Answer: A
Rationale: The correct sequence is inspection, auscultation, palpation to avoid altering bowel sounds or causing discomfort during the exam.