Nokea
The elderly client is admitted to the emergency department from a long-term care facility. The client has multiple ecchymotic areas on the body. The client is receiving digoxin, a cardiac glycoside; Lasix, a loop diuretic; Coumadin, an anticoagulant; and Xanax, an antianxiety medication. Which order should the nurse request from the health-care provider?
- A. A STAT serum potassium level.
- B. An order to admit to the hospital for observation.
- C. An order to administer Valium intravenous push.
- D. A STAT international normalized ratio (INR).
Correct Answer: D
Rationale: Ecchymosis with Coumadin suggests bleeding risk; STAT INR assesses anticoagulation status, guiding reversal if needed. Potassium, admission, or Valium are less urgent.
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The client diagnosed with diabetes insipidus is receiving vasopressin intranasally. Which assessment data indicate the medication is effective?
- A. The client reports being able to breathe through the nose.
- B. The client complains of being thirsty all the time.
- C. The client has a blood glucose of 99 mg/dL.
- D. The client is urinating every three (3) to four (4) hours.
Correct Answer: D
Rationale: Vasopressin reduces polyuria in diabetes insipidus; urination every 3–4 hours indicates effectiveness. Nasal breathing, thirst, or glucose are unrelated.
The client diagnosed with angina must receive a two (2)-inch nitroglycerin paste (Nitro-Bid) application. Which interventions should the nurse implement? Select all that apply.
- A. Wear gloves when administering.
- B. Remove the old Nitro-Bid paper.
- C. Apply the paper on a hairy spot.
- D. Put medication only on the legs.
- E. Report any headache to the HCP.
Correct Answer: A,B
Rationale: Gloves prevent nurse absorption, and removing old paste ensures accurate dosing. Hairy spots reduce adhesion, leg-only application is incorrect, and headaches are expected.
The client is diagnosed with pernicious anemia. Which health-care provider order should the nurse anticipate in treating this condition?
- A. Subcutaneous iron dextran.
- B. Intramuscular vitamin B12.
- C. Intravenous folic acid.
- D. Oral thiamine medication.
Correct Answer: B
Rationale: Pernicious anemia results from B12 deficiency; IM B12 is standard treatment due to absorption issues. Iron, folic acid, or thiamine do not address the primary cause.
A client who has Hodgkin's disease receives a weekly IV dose of nitrogen mustard. Which nursing order is most appropriate for this client?
- A. Encourage mouth care with an astringent mouthwash and dental floss after every meal
- B. Encourage organ meats and dried beans and peas
- C. Monitor vital signs daily
- D. Encourage fluid intake to 3000 cc
Correct Answer: D
Rationale: Nitrogen mustard causes bone marrow suppression and nausea; high fluid intake helps flush the drug and prevent dehydration.
The client who has had a kidney transplant tells the nurse he has been taking St. John's wort, an herb, for depression. Which action should the nurse take first?
- A. Praise the client for taking the initiative to treat the depression.
- B. Remain nonjudgmental about the client's alternative treatments.
- C. Refer the client to a psychologist for counseling for depression.
- D. Instruct the client to quit taking the medication immediately.
Correct Answer: D
Rationale: St. John’s wort induces CYP3A4, reducing immunosuppressant efficacy (e.g., cyclosporine), risking transplant rejection. Stopping it is the priority.