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The doctor has ordered neurological checks every 30 minutes for a client injured in a biking accident. Which finding indicates that the client's condition is satisfactory?
- A. A score of 13 on the Glascow coma scale
- B. The presence of doll's eye movement
- C. The absence of deep tendon reflexes
- D. Decerebrate posturing
Correct Answer: A
Rationale: A Glasgow Coma Scale score of 13 indicates mild brain injury, suggesting a satisfactory condition compared to the other abnormal findings.
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A client prescribed furosemide (Lasix) should choose which meal for lunch?
- A. chicken breast, white rice, apple
- B. turkey sandwich on wheat bread, celery sticks, grapefruit
- C. egg salad, cooked carrots, strawberries
- D. baked salmon, spinach salad, banana
Correct Answer: D
Rationale: Furosemide causes potassium loss. A meal with potassium-rich foods (e.g., spinach, banana) helps maintain electrolyte balance.
The nurse is caring for a client admitted with chest pain and atrial fibrillation. The nurse accidentally gives the client the wrong dose of digoxin. The client is monitored throughout the shift and no ill effects are noted. Which actions by the nurse are correct? Select all that apply.
- A. fill out an incident report and make a note of it in the nurse's notes
- B. print out rhythm strips every 2 hours and place on the client's chart
- C. fill out an incident report and notify the health care provider for further orders
- D. notify the health care provider at the end of the shift, since no ill effects were observed
- E. notify the pharmacy that they loaded the wrong dose in the automatic medication dispensing system
Correct Answer: C
Rationale: Filling out an incident report and notifying the provider immediately are necessary to address the medication error and ensure client safety, even if no ill effects were observed.
A client with iron-deficiency anemia is taking an oral iron supplement. The nurse should tell the client to take the medication with:
- A. Orange juice
- B. Water only
- C. Milk
- D. Apple juice
Correct Answer: A
Rationale: Orange juice, rich in vitamin C, enhances the absorption of oral iron supplements.
A child with thrush has been prescribed fluconazole (Diflucan). The child's mother asks what this medication is used for, and the nurse correctly replies,
- A. This is an antiviral medication used to treat your child's viral infection.'
- B. This medication is used to treat yeast infections.'
- C. This medication is an analgesic that will ease your child's pain while eating.'
- D. This is an antibiotic for your child's bacterial infection.'
Correct Answer: B
Rationale: Fluconazole is an antifungal used to treat thrush, a yeast infection caused by Candida.
The nurse is reviewing the lab results of four clients. Which finding should be reported to the physician?
- A. A client with chronic renal failure with a serum creatinine of 5.6 mg/dL
- B. A client with rheumatic fever with a positive C reactive protein
- C. A client with gastroenteritis with a hematocrit of 52%
- D. A client with epilepsy with a white cell count of 3,800 mm³
Correct Answer: C
Rationale: A hematocrit of 52% in gastroenteritis suggests dehydration, which requires immediate reporting.