Nokea
The healthcare provider prescribes lactulose for a patient with hepatic encephalopathy. What will the nurse assess to determine the effectiveness of this medication?
- A. Decreased ammonia levels
- B. Relief of constipation
- C. Decreased liver enzymes
- D. Relief of abdominal pain
Correct Answer: A
Rationale: Lactulose works by reducing blood ammonia levels, which is its primary mechanism in treating hepatic encephalopathy.
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A nurse is caring for a client who has a pulmonary embolism and has a new prescription for enoxaparin 1.5 mg/kg/dose subcutaneously every 12 hours. The client weighs 245 lbs. How many mg should the nurse administer per dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer: 167
Rationale: Calculation: 245 lbs ÷ 2.2 = 111.36 kg; 111.36 kg × 1.5 mg/kg = 167 mg
A nurse is preparing to administer a 2 mg IV bolus of morphine sulfate. Morphine sulfate is available in a concentration of 10 mg/mL. How many mL should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer: 0.2
Rationale: Calculation: 2 mg ÷ 10 mg/mL = 0.2 mL
A nurse is monitoring an older adult female client who had a myocardial infarction (MI) for the development of an acute kidney injury (AKI). Which of the following findings indicate an increased risk of acute kidney injury (AKI)?
- A. Blood urea nitrogen (BUN) 20 mg/dL
- B. Serum Osmolality 290 mOsm/kg H2O
- C. Magnesium 2.0 mEq/L
- D. Serum creatinine 1.8 mg/dL
Correct Answer: D
Rationale: Elevated creatinine indicates renal impairment and increased AKI risk post-MI.
A client is admitted to the emergency room with renal calculi. Upon assessment, which of the following findings should the nurse expect?
- A. Bradycardia
- B. Bradypnea
- C. Severe pain
- D. Nocturia
Correct Answer: C
Rationale: Severe pain (renal colic) is the most common symptom of renal calculi, caused by the stone moving and blocking the ureter.
A nurse is caring for a client who has a T-4 spinal cord injury. Which of the following findings should the nurse identify as a potential cause for autonomic dysreflexia?
- A. The client's bladder becomes distended.
- B. The client states having a severe headache.
- C. The client states having nasal congestion.
- D. The client's blood pressure becomes elevated.
Correct Answer: A
Rationale: A distended bladder is a common cause of autonomic dysreflexia. It can trigger an exaggerated response from the autonomic nervous system, leading to a rapid increase in blood pressure.